Provider Demographics
NPI:1902849094
Name:NICHOLSON, LES EDWARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:LES
Middle Name:EDWARD
Last Name:NICHOLSON
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 1:2220 CHEAT RD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-4453
Mailing Address - Country:US
Mailing Address - Phone:304-594-1499
Mailing Address - Fax:304-594-0150
Practice Address - Street 1:2220 CHEAT RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26508-4453
Practice Address - Country:US
Practice Address - Phone:304-594-1499
Practice Address - Fax:304-594-0150
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0136227000Medicaid