MEDICARE: DR. KEITH NICHOLSON D.D.S

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8795/879	KY
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8644	NC
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	12012234A	IN
4	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	DS043962	PA
5	122300000X	Dentist	8644	NC

General Provider Information

NPI Number	:	1093959660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KEITH NICHOLSON D.D.S

Provider Business Mailing Address
First Line	:	UNIVERSITY OF LOUISVILLE
Second Line	:	501 SOUTH PRESTON ST.
City	:	LOUISVILLE
State	:	KY
Zip	:	40292-0001
Country	:	US
Telephone Number	:	502-852-5124
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 S BROAD ST STE 1530
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19110-1026
Country	:	US
Telephone Number	:	267-691-0606
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2009
Last Update Date	:	05/28/2023

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