Healthcare Provider Details

I. General information

NPI: 1649236696
Provider Name (Legal Business Name): BRENT EUGENE NIKOLAUS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81ST DS/SGD 606 FISHER ST, BLDG 0824
KEESLER AFB MS
39534-2567
US

IV. Provider business mailing address

3810 POINT CLEAR DR
OCEAN SPRINGS MS
39564-8193
US

V. Phone/Fax

Practice location:
  • Phone: 228-377-5890
  • Fax:
Mailing address:
  • Phone: 228-818-9412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDS0000004593
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: