Provider Demographics
NPI:1982879649
Name:KENT N NICKLAS DDS INC.
Entity Type:Organization
Organization Name:KENT N NICKLAS DDS INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:KENT
Authorized Official - Middle Name:N
Authorized Official - Last Name:NICKLAS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:440-234-4646
Mailing Address - Street 1:633 W BAGLEY RD
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:OH
Mailing Address - Zip Code:44017-1356
Mailing Address - Country:US
Mailing Address - Phone:440-234-4646
Mailing Address - Fax:440-234-1868
Practice Address - Street 1:633 W BAGLEY RD
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:OH
Practice Address - Zip Code:44017-1356
Practice Address - Country:US
Practice Address - Phone:440-234-4646
Practice Address - Fax:440-234-1868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-24
Last Update Date:2008-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH189941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty