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General NPI Number Information
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NPI Number | 1609259696
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Entity Type | Individual
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Provider Name | NICKLAUS HEATH D.D.S
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Gender | Male
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Dates
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Enumeration Date | 07/08/2015
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Last Update Date | 01/03/2017
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Provider Practice Location Address
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Address Line | 2670 S FERDON BLVD
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City | CRESTVIEW
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State | FL
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Zip | 32536-5480
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Country | US
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Telephone | 850-634-0748
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Fax |
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Provider Business Mailing Address
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Address Line | 1721 N 20TH AVE
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City | PENSACOLA
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State | FL
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Zip | 32503-5758
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Country | US
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Telephone | 850-384-8798
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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 | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 22161
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License Number State | FL
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