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General NPI Number Information
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NPI Number | 1689085474
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Entity Type | Individual
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Provider Name | JONATHAN ROBERT NICHOLS D.M.D.
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Gender | Male
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Dates
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Enumeration Date | 05/14/2014
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Last Update Date | 09/01/2016
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Provider Practice Location Address
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Address Line | 6643 U S HIGHWAY 98
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City | HATTIESBURG
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State | MS
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Zip | 39402-8442
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Country | US
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Telephone | 601-450-6060
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Fax | 601-450-6062
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Provider Business Mailing Address
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Address Line | 6643 HIGHWAY 98
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City | HATTIESBURG
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State | MS
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Zip | 39402
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Country | US
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Telephone | 601-450-6060
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Fax | 601-450-6062
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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 | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 3761-14
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License Number State | MS
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