Healthcare Provider Details

I. General information

NPI: 1528131901
Provider Name (Legal Business Name): CORNELIUS ADOLPHUS NICHOLSON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 05/02/2018
Certification Date:
Deactivation Date: 01/30/2008
Reactivation Date: 05/02/2018

III. Provider practice location address

2815 S MCCLELLAN ST
SEATTLE WA
98144-5407
US

IV. Provider business mailing address

2815 S MCCLELLAN ST
SEATTLE WA
98144-5407
US

V. Phone/Fax

Practice location:
  • Phone: 206-722-5000
  • Fax: 206-721-1428
Mailing address:
  • Phone: 206-722-5000
  • Fax: 206-721-1428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number6379
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: