Provider Demographics
NPI:1982640165
Name:NICKLAS, WILLIAM GRANT (DMD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GRANT
Last Name:NICKLAS
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 1:301 OXFORD VALLEY RD
Mailing Address - Street 2:301A
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-7706
Mailing Address - Country:US
Mailing Address - Phone:215-493-8485
Mailing Address - Fax:
Practice Address - Street 1:301 OXFORD VALLEY RD
Practice Address - Street 2:301A
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-7706
Practice Address - Country:US
Practice Address - Phone:215-493-8485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS20762L204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery