Provider Demographics
NPI:1376730853
Name:DR RICHARD NICHOLS ORTHODONTICS
Entity type:Organization
Organization Name:DR RICHARD NICHOLS ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIRANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DYKEN
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:406-586-8727
Mailing Address - Street 1:208 N 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715
Mailing Address - Country:US
Mailing Address - Phone:406-586-8727
Mailing Address - Fax:406-586-9382
Practice Address - Street 1:208 N 11TH AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715
Practice Address - Country:US
Practice Address - Phone:406-586-8727
Practice Address - Fax:406-586-9382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT13041223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty