Healthcare Provider Details

I. General information

NPI: 1568082493
Provider Name (Legal Business Name): NICHOLE ECKRICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 07/20/2026
Certification Date: 07/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 EAST HOSPITAL ROAD BUILDING 320, ROOM A102
FORT GORDON GA
30905
US

IV. Provider business mailing address

5511 SHOOTING STAR TRL
RAPID CITY SD
57702-8867
US

V. Phone/Fax

Practice location:
  • Phone: 706-787-6927
  • Fax:
Mailing address:
  • Phone: 605-430-4486
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13396331-9926
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number13396331-9926
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: