Healthcare Provider Details

I. General information

NPI: 1326645623
Provider Name (Legal Business Name): MARTHA DAWSON NICHOLSON DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 SPRING ST
DOVER TN
37058-3302
US

IV. Provider business mailing address

5460 ASHLAND CITY RD
CLARKSVILLE TN
37043-8331
US

V. Phone/Fax

Practice location:
  • Phone: 931-232-5829
  • Fax:
Mailing address:
  • Phone: 931-542-8742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number11347
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: