Provider Demographics
NPI:1649346016
Name:NICKELL, JACQUELINE G (DDS)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:G
Last Name:NICKELL
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 CENTER ST
Mailing Address - Street 2:STE F
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694
Mailing Address - Country:US
Mailing Address - Phone:740-574-8150
Mailing Address - Fax:
Practice Address - Street 1:613 CENTER ST
Practice Address - Street 2:STE F
Practice Address - City:WHEELERSBURG
Practice Address - State:OH
Practice Address - Zip Code:45694
Practice Address - Country:US
Practice Address - Phone:740-574-8150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20117122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist