Healthcare Provider Details

I. General information

NPI: 1427189224
Provider Name (Legal Business Name): MICHAEL R NICHOLS D.M.D., M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 KATHERINE DR
JACKSON MS
39232-8801
US

IV. Provider business mailing address

266 KATHERINE DR
JACKSON MS
39232-8801
US

V. Phone/Fax

Practice location:
  • Phone: 601-420-3223
  • Fax: 601-420-3054
Mailing address:
  • Phone: 601-420-3223
  • Fax: 601-420-3054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number3119-00
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberOS-340-00
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: