Healthcare Provider Details

I. General information

NPI: 1376281873
Provider Name (Legal Business Name): BRANDON NICOLL DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2022
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5240 N TOWNE CENTRE DR STE 201
OZARK MO
65721-9075
US

IV. Provider business mailing address

400 RIVERWALK TER STE 250
JENKS OK
74037-5619
US

V. Phone/Fax

Practice location:
  • Phone: 417-581-0000
  • Fax: 417-582-1564
Mailing address:
  • Phone: 918-998-0996
  • Fax: 918-235-9079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2022017990
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: