Provider Demographics
NPI:1700253622
Name:DR. HOLLY J. NICHOLS, DMD, PC
Entity Type:Organization
Organization Name:DR. HOLLY J. NICHOLS, DMD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:J
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:541-296-9415
Mailing Address - Street 1:308 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:THE DALLES
Mailing Address - State:OR
Mailing Address - Zip Code:97058-2208
Mailing Address - Country:US
Mailing Address - Phone:541-296-9415
Mailing Address - Fax:541-296-8846
Practice Address - Street 1:308 E 4TH ST
Practice Address - Street 2:
Practice Address - City:THE DALLES
Practice Address - State:OR
Practice Address - Zip Code:97058-2208
Practice Address - Country:US
Practice Address - Phone:541-296-9415
Practice Address - Fax:541-296-8846
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD7013261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1568539617OtherNPI