Provider Demographics
NPI:1245348960
Name:NICHOLS, JEFFREY TODD (DMD)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:TODD
Last Name:NICHOLS
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 1:1709 CHICKASAW DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-1430
Mailing Address - Country:US
Mailing Address - Phone:662-241-4952
Mailing Address - Fax:
Practice Address - Street 1:2401 5TH ST N
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-2005
Practice Address - Country:US
Practice Address - Phone:662-713-1111
Practice Address - Fax:662-713-1113
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2882-95122300000X
AL5389 C122300000X, 1223P0300X
MSPER-323-981223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered122300000XDental ProvidersDentist
Not Answered1223P0300XDental ProvidersDentistPeriodontics