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NPI Code Detail

MEDICARE: KATELYN NICHOLS

MEDICARE: KATELYN NICHOLS
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
11223D0001XPublic Health DentistryD10277OR
2122300000XDentistD10277OR

General Provider Information

NPI Number : 1073997086
Entity Type Code : Individual
Provider Name (Legal Business Name) : KATELYN NICHOLS
Provider Business Mailing Address
First Line : 1880 LANCASTER DR NE STE 121
Second Line :
City : SALEM
State : OR
Zip : 97305-1069
Country : US
Telephone Number : 971-600-3498
Fax Number :
Provider Business Practice Location Address
First Line : 1880 LANCASTER DR NE STE 121
Second Line :
City : SALEM
State : OR
Zip : 97305-1069
Country : US
Telephone Number : 971-600-3498
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/20/2015
Last Update Date : 03/21/2022

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Directions to “ KATELYN NICHOLS ” Practice Location

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