Provider Demographics
NPI:1255718169
Name:DWAN, NICHOLAS (DDS)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:DWAN
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 1:3333 S SUNNYSLOPE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-4504
Mailing Address - Country:US
Mailing Address - Phone:262-505-1000
Mailing Address - Fax:262-505-1019
Practice Address - Street 1:3333 S SUNNYSLOPE RD STE 100
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4504
Practice Address - Country:US
Practice Address - Phone:262-505-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-29
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1001083-151223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice