Provider Demographics
NPI:1750596938
Name:JAMES A NICHOLSON DDS PA
Entity type:Organization
Organization Name:JAMES A NICHOLSON DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS MS
Authorized Official - Phone:601-268-1111
Mailing Address - Street 1:120 SOUTH 28TH AVENUE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39465
Mailing Address - Country:US
Mailing Address - Phone:601-268-1111
Mailing Address - Fax:601-268-2888
Practice Address - Street 1:120 SOUTH 28TH AVENUE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39465
Practice Address - Country:US
Practice Address - Phone:601-268-1111
Practice Address - Fax:601-268-2888
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS68631223X0400X
MS194181122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04682721Medicaid