Healthcare Provider Details

I. General information

NPI: 1780574160
Provider Name (Legal Business Name): CHRISTOPHER NUCKOLS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2025
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10590 ENDURING FREEDOM DR
FORT DRUM NY
13602-5503
US

IV. Provider business mailing address

10590 ENDURING FREEDOM DR
FORT DRUM NY
13602-5503
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8751
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number016.0134372
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: