MEDICARE: THOMAS A NUCKOLS DDS PA

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	5689	KS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	116846	OTHER	KS	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1801856000
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THOMAS A NUCKOLS DDS PA

Provider Business Mailing Address
First Line	:	310 SW FIRST
Second Line	:	PO BOX 57
City	:	PLAINVILLE
State	:	KS
Zip	:	67663-0057
Country	:	US
Telephone Number	:	785-434-4565
Fax Number	:	785-688-4105

Provider Business Practice Location Address
First Line	:	310 SW FIRST
Second Line	:
City	:	PLAINVILLE
State	:	KS
Zip	:	67663-0057
Country	:	US
Telephone Number	:	785-434-4565
Fax Number	:	785-688-4105

Authorized Official
Title or Position	:	PRESIDENT
Name	:	THOMAS ARTHUR NUCKOLS
Credential	:	DDS
Telephone Number	:	785-434-4565

Provider Enumeration Date	:	03/23/2006
Last Update Date	:	01/10/2013

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