Provider Demographics
NPI:1669543310
Name:NICHOLS, TERRY EMMITT (DMD)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:EMMITT
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:PO BOX 614
Mailing Address - Street 2:966 7TH AVE
Mailing Address - City:GRACEVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32440
Mailing Address - Country:US
Mailing Address - Phone:850-263-6400
Mailing Address - Fax:850-263-4717
Practice Address - Street 1:966 7TH AVE
Practice Address - Street 2:
Practice Address - City:GRACEVILLE
Practice Address - State:FL
Practice Address - Zip Code:32440
Practice Address - Country:US
Practice Address - Phone:850-263-6400
Practice Address - Fax:850-263-4717
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN00127621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
995851OtherORAL HEALTH SERVICES