Provider Demographics
NPI:1881794386
Name:NICHOLSON, STEVEN EARL (DMD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:EARL
Last Name:NICHOLSON
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 1:324 SAINT JOHNS RD
Mailing Address - Street 2:
Mailing Address - City:DRUMS
Mailing Address - State:PA
Mailing Address - Zip Code:18222-1607
Mailing Address - Country:US
Mailing Address - Phone:570-788-4974
Mailing Address - Fax:
Practice Address - Street 1:14 S CEDAR ST
Practice Address - Street 2:
Practice Address - City:HAZLETON
Practice Address - State:PA
Practice Address - Zip Code:18201-6602
Practice Address - Country:US
Practice Address - Phone:570-455-6275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-24
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS-028823-L1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017194170001OtherMEDICAL ACCESS
PA0008024OtherDORAL-AMERIHEALTH MERCY
PA000000020320OtherGATEWAY
PA85672OtherUNISON MED PLUS
PA761232OtherUNITED CONCORDIA