Healthcare Provider Details

I. General information

NPI: 1629968771
Provider Name (Legal Business Name): BRIAN ANTHONY NICHOLSON DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1625 CHESTNUT ST STE 228
PHILADELPHIA PA
19103-4216
US

IV. Provider business mailing address

4210 SANSOM ST APT 401
PHILADELPHIA PA
19104-3589
US

V. Phone/Fax

Practice location:
  • Phone: 215-336-8399
  • Fax:
Mailing address:
  • Phone: 561-213-2795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS045147
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: