Provider Demographics
NPI:1184368953
Name:BRENT O NICHOLS DDS APC
Entity type:Organization
Organization Name:BRENT O NICHOLS DDS APC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:O
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-724-9072
Mailing Address - Street 1:18800 DELAWARE ST STE 600
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6017
Mailing Address - Country:US
Mailing Address - Phone:714-724-9072
Mailing Address - Fax:714-960-2699
Practice Address - Street 1:18800 DELAWARE ST STE 600
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-6017
Practice Address - Country:US
Practice Address - Phone:714-960-2600
Practice Address - Fax:714-960-2699
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-26
Last Update Date:2022-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46509OtherDENTAL