Healthcare Provider Details

I. General information

NPI: 1245244474
Provider Name (Legal Business Name): CHARLES THOMAS NUCKOLS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 01/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 EASTWOOD AVE
BOWLING GREEN KY
42103-1688
US

IV. Provider business mailing address

627 EASTWOOD AVE
BOWLING GREEN KY
42103-1688
US

V. Phone/Fax

Practice location:
  • Phone: 270-843-4341
  • Fax: 270-746-9551
Mailing address:
  • Phone: 270-843-4341
  • Fax: 270-746-9551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3399
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number3399
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: