Healthcare Provider Details

I. General information

NPI: 1669532420
Provider Name (Legal Business Name): JOEL M NICHOLS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 04/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-1100
US

IV. Provider business mailing address

9900 LINCOLN ST FL 2
TACOMA WA
98431-1100
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-3885
  • Fax: 253-968-3278
Mailing address:
  • Phone: 253-968-4039
  • Fax: 253-968-5919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2004013594
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number60299
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: