Healthcare Provider Details

I. General information

NPI: 1114331253
Provider Name (Legal Business Name): JOSEPH J. NICOLS JR DDS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

714 MONTAUK HWY
WEST ISLIP NY
11795-4421
US

IV. Provider business mailing address

714 MONTAUK HWY
WEST ISLIP NY
11795-4421
US

V. Phone/Fax

Practice location:
  • Phone: 631-587-9766
  • Fax:
Mailing address:
  • Phone: 631-587-9766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number023442
License Number StateNY

VIII. Authorized Official

Name: DR. JOSEPH JAMES NICOLS JR.
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 631-587-9766