Provider Demographics
NPI:1215978655
Name:NICHOLSON, SPENCER CHONG (DDS)
Entity type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:CHONG
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 1:4533 DELAINA DR
Mailing Address - Street 2:
Mailing Address - City:FLOWER MOUND
Mailing Address - State:TX
Mailing Address - Zip Code:75022-0994
Mailing Address - Country:US
Mailing Address - Phone:630-433-0135
Mailing Address - Fax:
Practice Address - Street 1:808 NE MALL BLVD
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-4653
Practice Address - Country:US
Practice Address - Phone:817-595-9675
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2021-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190255941223G0001X
TX359771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice