MEDICARE: DR. RICHARD DALE NICHOLS DDS

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	122300000X	Dentist	30014979	OH

General Provider Information

NPI Number	:	1629184791
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD DALE NICHOLS DDS

Provider Business Mailing Address
First Line	:	1674 PIN OAK TRAIL
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-3652
Country	:	US
Telephone Number	:	419-774-0414
Fax Number	:

Provider Business Practice Location Address
First Line	:	552 S TRIMBLE RD
Second Line	:
City	:	MANSFIELD
State	:	OH
Zip	:	44906-3418
Country	:	US
Telephone Number	:	419-756-0188
Fax Number	:	419-774-9671

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

Provider Enumeration Date	:	08/22/2006
Last Update Date	:	07/31/2009

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