Healthcare Provider Details

I. General information

NPI: 1659580611
Provider Name (Legal Business Name): SEAN D NICKENS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 04/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 PAXTON PL STE 104
LITITZ PA
17543-8279
US

IV. Provider business mailing address

620 PAXTON PL STE 104
LITITZ PA
17543-8279
US

V. Phone/Fax

Practice location:
  • Phone: 717-569-7645
  • Fax: 717-569-7650
Mailing address:
  • Phone: 717-569-7645
  • Fax: 717-569-7650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS035854
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: