Provider Demographics
NPI:1063432581
Name:DR DANA M NICHOLS AND ASSOC INC
Entity type:Organization
Organization Name:DR DANA M NICHOLS AND ASSOC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:937-845-9422
Mailing Address - Street 1:PO BOX 66
Mailing Address - Street 2:203 E LAKE AVE
Mailing Address - City:NEW CARLISLE
Mailing Address - State:OH
Mailing Address - Zip Code:45344
Mailing Address - Country:US
Mailing Address - Phone:937-845-9422
Mailing Address - Fax:937-845-8280
Practice Address - Street 1:203 E LAKE AVE
Practice Address - Street 2:
Practice Address - City:NEW CARLISLE
Practice Address - State:OH
Practice Address - Zip Code:45344
Practice Address - Country:US
Practice Address - Phone:937-845-9422
Practice Address - Fax:937-845-8280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH21982122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2504267Medicaid