Healthcare Provider Details

I. General information

NPI: 1467611517
Provider Name (Legal Business Name): TIMOTHY DANIEL NICHOLS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4383 TENNYSON ST 1F
DENVER CO
80212-2363
US

IV. Provider business mailing address

721 JUDSON ST
LONGMONT CO
80501-4818
US

V. Phone/Fax

Practice location:
  • Phone: 303-423-4383
  • Fax: 303-416-4420
Mailing address:
  • Phone: 303-994-0213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number9211
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: