Provider Demographics
NPI:1881783595
Name:NICHOLS, JUSTIN M (DDS)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:M
Last Name:NICHOLS
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 1:4904 S MINNESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108-2864
Mailing Address - Country:US
Mailing Address - Phone:605-335-8640
Mailing Address - Fax:605-332-9956
Practice Address - Street 1:4904 S MINNESOTA AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108-2864
Practice Address - Country:US
Practice Address - Phone:605-335-8640
Practice Address - Fax:605-332-9956
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDD0522122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD911864477OtherTIN OF PDC