Provider Demographics
NPI:1700940822
Name:NICKELL, BRYAN JOSEPH (DDS)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:JOSEPH
Last Name:NICKELL
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 1:6 SYCAMORE CREEK DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SPRINGBORO
Mailing Address - State:OH
Mailing Address - Zip Code:45066-2300
Mailing Address - Country:US
Mailing Address - Phone:937-748-8250
Mailing Address - Fax:937-748-1402
Practice Address - Street 1:6 SYCAMORE CREEK DR
Practice Address - Street 2:SUITE C
Practice Address - City:SPRINGBORO
Practice Address - State:OH
Practice Address - Zip Code:45066-2300
Practice Address - Country:US
Practice Address - Phone:937-748-8250
Practice Address - Fax:937-748-1402
Is Sole Proprietor?:No
Enumeration Date:2006-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH213801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1598548OtherGROUP #