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General NPI Number Information
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NPI Number | 1093959660
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Entity Type | Individual
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Provider Name | KEITH NICHOLSON D.D.S
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Gender | Male
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Dates
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Enumeration Date | 04/27/2009
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Last Update Date | 05/28/2023
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Provider Practice Location Address
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Address Line | 100 S BROAD ST STE 1530
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City | PHILADELPHIA
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State | PA
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Zip | 19110-1026
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Country | US
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Telephone | 267-691-0606
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Fax |
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Provider Business Mailing Address
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Address Line | UNIVERSITY OF LOUISVILLE 501 SOUTH PRESTON ST.
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City | LOUISVILLE
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State | KY
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Zip | 40292-0001
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Country | US
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Telephone | 502-852-5124
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 8795/879
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 8644
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 12012234A
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License Number State | IN
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Taxonomy #4
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | DS043962
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License Number State | PA
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Taxonomy #5
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 8644
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License Number State | NC
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