Provider Demographics
NPI:1265553820
Name:NICHOLS, THOMAS ROBERT (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:ROBERT
Last Name:NICHOLS
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 1:215 S STURGEON
Mailing Address - Street 2:SUITE C
Mailing Address - City:MONTGOMERY CITY
Mailing Address - State:MO
Mailing Address - Zip Code:63361
Mailing Address - Country:US
Mailing Address - Phone:573-564-3726
Mailing Address - Fax:573-564-2788
Practice Address - Street 1:215 S STURGEON
Practice Address - Street 2:SUITE C
Practice Address - City:MONTGOMERY CITY
Practice Address - State:MO
Practice Address - Zip Code:63361
Practice Address - Country:US
Practice Address - Phone:573-564-3726
Practice Address - Fax:573-564-2788
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO133381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice