1326223843 NPI number — TERRY E NICHOLS DMD PA

Table of content: (NPI 1326223843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326223843 NPI number — TERRY E NICHOLS DMD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TERRY E NICHOLS DMD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326223843
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 614
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRACEVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32440-0614
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-263-6400
Provider Business Mailing Address Fax Number:
850-263-4717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
966 7TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRACEVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32440-2224
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-263-6400
Provider Business Practice Location Address Fax Number:
850-263-4717
Provider Enumeration Date:
01/03/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NICHOLS
Authorized Official First Name:
TERRY
Authorized Official Middle Name:
EMMETT
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
850-263-6400

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)