Healthcare Provider Details

I. General information

NPI: 1417182916
Provider Name (Legal Business Name): NATHANIEL T NICHOLSON D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2009
Last Update Date: 11/07/2021
Certification Date: 11/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8221 RITCHIE HWY STE 201
PASADENA MD
21122-3941
US

IV. Provider business mailing address

8221 RITCHIE HWY STE 201
PASADENA MD
21122-3941
US

V. Phone/Fax

Practice location:
  • Phone: 410-647-3453
  • Fax: 410-647-3454
Mailing address:
  • Phone: 410-647-3453
  • Fax: 410-647-3454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3860
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number15392
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: