Healthcare Provider Details

I. General information

NPI: 1598473431
Provider Name (Legal Business Name): ALIAH FUELLER NICHOLS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3141 BEAUMONT CENTRE CIR STE 200
LEXINGTON KY
40513-1956
US

IV. Provider business mailing address

105 SPRUCE ST
LEXINGTON KY
40507-2109
US

V. Phone/Fax

Practice location:
  • Phone: 859-296-4846
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number123456
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: