MEDICARE: NICHOL FAMILY DENTISTRY, LLC

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

General Provider Information

NPI Number	:	1023773488
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NICHOL FAMILY DENTISTRY, LLC

Provider Business Mailing Address
First Line	:	6459 OMAHA BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-2618
Country	:	US
Telephone Number	:	719-597-9057
Fax Number	:	719-597-2189

Provider Business Practice Location Address
First Line	:	6459 OMAHA BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80915-2618
Country	:	US
Telephone Number	:	719-597-9057
Fax Number	:	719-597-2189

Authorized Official
Title or Position	:	DENTIST
Name	:	DR. BRENT AUSTIN NICHOL
Credential	:	DMD
Telephone Number	:	719-597-9057

Provider Enumeration Date	:	11/01/2021
Last Update Date	:	11/01/2021

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