Healthcare Provider Details

I. General information

NPI: 1477707784
Provider Name (Legal Business Name): NUCKOLS & COHRON, P.S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2008
Last Update Date: 11/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

627 EASTWOOD ST
BOWLING GREEN KY
42103-1688
US

IV. Provider business mailing address

627 EASTWOOD ST P. O. BOX 70130
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

VIII. Authorized Official

Name: DR. CHARLES T NUCKOLS
Title or Position: OWNER
Credential: DMD
Phone: 270-843-4341