Provider Demographics
NPI:1154395259
Name:NICHOLSON, SCOTT KEVIN (DMD)
Entity type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:KEVIN
Last Name:NICHOLSON
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 1:715 ELM ST SW
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:OR
Mailing Address - Zip Code:97321-1935
Mailing Address - Country:US
Mailing Address - Phone:541-928-6650
Mailing Address - Fax:541-812-0150
Practice Address - Street 1:715 ELM ST SW
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:OR
Practice Address - Zip Code:97321-1935
Practice Address - Country:US
Practice Address - Phone:541-928-6650
Practice Address - Fax:541-928-6650
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD60961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice