Healthcare Provider Details

I. General information

NPI: 1598086001
Provider Name (Legal Business Name): JASON DANIEL NICHOLSON D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2010
Last Update Date: 01/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 NW 23RD ST SUITE 23
OKLAHOMA CITY OK
73107-2442
US

IV. Provider business mailing address

1355 N UNIVERSITY AVE SUITE #110
PROVO UT
84604
US

V. Phone/Fax

Practice location:
  • Phone: 405-942-0337
  • Fax:
Mailing address:
  • Phone: 385-309-0309
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number9410532-9923
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: