Provider Demographics
NPI:1972118396
Name:MAXIM, NICOLAS TANNER (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICOLAS
Middle Name:TANNER
Last Name:MAXIM
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 1:9010 SW OAK ST APT 116
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-6587
Mailing Address - Country:US
Mailing Address - Phone:804-337-5620
Mailing Address - Fax:
Practice Address - Street 1:14845 SW MURRAY SCHOLLS DR STE 113
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007-9237
Practice Address - Country:US
Practice Address - Phone:503-590-7574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD113261223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice