Healthcare Provider Details

I. General information

NPI: 1104719434
Provider Name (Legal Business Name): NICHOLAS CHAMBERLAIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3110 NIEDER RD
LAWRENCE KS
66047-1950
US

IV. Provider business mailing address

5639 NALL AVE
ROELAND PARK KS
66202-1941
US

V. Phone/Fax

Practice location:
  • Phone: 785-592-6652
  • Fax:
Mailing address:
  • Phone: 479-621-3453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number62350
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: