Healthcare Provider Details

I. General information

NPI: 1497024111
Provider Name (Legal Business Name): STEPHEN GRIGSBY NICHOLSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2011
Last Update Date: 12/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W MILL ST
BAYFIELD CO
81122
US

IV. Provider business mailing address

P.O. BOX 389
BAYFIELD CO
81122
US

V. Phone/Fax

Practice location:
  • Phone: 970-884-9306
  • Fax: 970-884-9675
Mailing address:
  • Phone: 970-884-9306
  • Fax: 970-884-9675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberH-D-100898
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: