MEDICARE: PATRICIA M NICKLAS DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	30-020038	OH

General Provider Information

NPI Number	:	1023230414
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PATRICIA M NICKLAS DDS

Provider Business Mailing Address
First Line	:	201 W 8TH ST
Second Line	:	SUITE 810
City	:	PUEBLO
State	:	CO
Zip	:	81003-3038
Country	:	US
Telephone Number	:	719-562-4447
Fax Number	:

Provider Business Practice Location Address
First Line	:	6035 RIVERS AVE STE A
Second Line	:
City	:	NORTH CHARLESTON
State	:	SC
Zip	:	29406-5018
Country	:	US
Telephone Number	:	843-572-9909
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	12/29/2010

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