Healthcare Provider Details

I. General information

NPI: 1528153343
Provider Name (Legal Business Name): CORNELIUS A. NICHOLSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 04/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

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 Code261QD0000X
TaxonomyDental Clinic/Center
License Number6379
License Number StateWA

VIII. Authorized Official

Name: DR. CORNELIUS A NICHOLSON
Title or Position: PRESIDENT/ OWNER
Credential: DDS
Phone: 206-722-5000