=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578273165
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELEISHA J NICKOLES, DDS, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2022
-----------------------------------------------------
Last Update Date | 12/05/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1320 NATIONAL RD STE 1
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-242-8600
-----------------------------------------------------
Fax | 304-242-8665
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1320 NATIONAL RD STE 1
-----------------------------------------------------
City | WHEELING
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 26003-5706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-242-8600
-----------------------------------------------------
Fax | 304-242-8665
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ELEISHA JEAN NICKOLES
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 304-242-8600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------