Provider Demographics
NPI:1891102752
Name:WITHEM, NICHOLAS RICHARD (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:RICHARD
Last Name:WITHEM
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6588 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87402-5122
Mailing Address - Country:US
Mailing Address - Phone:805-729-3413
Mailing Address - Fax:
Practice Address - Street 1:6588 E MAIN ST
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-5122
Practice Address - Country:US
Practice Address - Phone:505-326-6800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-11
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD009005122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist