Provider Demographics
NPI:1134341407
Name:NICHOLS PERIODONTICS LLC
Entity type:Organization
Organization Name:NICHOLS PERIODONTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:662-713-1111
Mailing Address - Street 1:2401 5TH STREET NORTH
Mailing Address - Street 2:SUITE 2
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705
Mailing Address - Country:US
Mailing Address - Phone:662-713-1111
Mailing Address - Fax:662-713-1113
Practice Address - Street 1:2401 5TH STREET NORTH
Practice Address - Street 2:SUITE 2
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705
Practice Address - Country:US
Practice Address - Phone:662-713-1111
Practice Address - Fax:662-713-1113
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2882-951223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty