Provider Demographics
NPI:1902844731
Name:NICHOLS, MICHAEL W (DDS)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 CUMBERLAND LN
Mailing Address - Street 2:
Mailing Address - City:JACKSBORO
Mailing Address - State:TN
Mailing Address - Zip Code:37757-2737
Mailing Address - Country:US
Mailing Address - Phone:423-562-9459
Mailing Address - Fax:423-566-7195
Practice Address - Street 1:116 CUMBERLAND LN
Practice Address - Street 2:
Practice Address - City:JACKSBORO
Practice Address - State:TN
Practice Address - Zip Code:37757-2737
Practice Address - Country:US
Practice Address - Phone:423-562-9459
Practice Address - Fax:423-566-7195
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice