Healthcare Provider Details

I. General information

NPI: 1609259696
Provider Name (Legal Business Name): NICKLAUS HEATH D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2015
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2670 S FERDON BLVD
CRESTVIEW FL
32536-5480
US

IV. Provider business mailing address

1721 N 20TH AVE
PENSACOLA FL
32503-5758
US

V. Phone/Fax

Practice location:
  • Phone: 850-634-0748
  • Fax:
Mailing address:
  • Phone: 850-384-8798
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number22161
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: