MEDICARE: BRADEN JAMES NICKLE DMD

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	122300000X	Dentist	7790	OK

General Provider Information

NPI Number	:	1033895271
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADEN JAMES NICKLE DMD

Provider Business Mailing Address
First Line	:	2721 NW 172ND ST
Second Line	:
City	:	EDMOND
State	:	OK
Zip	:	73012-7000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5920 N MAY AVE
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73112-4277
Country	:	US
Telephone Number	:	405-494-4961
Fax Number	:

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

Provider Enumeration Date	:	06/22/2023
Last Update Date	:	06/22/2023

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