MEDICARE: J. WADE NICHOLS DMD, 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	1223E0200X	Endodontics	SC1956	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1851516884
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	J. WADE NICHOLS DMD, PA

Provider Business Mailing Address
First Line	:	4605 OLEANDER DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5739
Country	:	US
Telephone Number	:	843-554-5300
Fax Number	:	843-554-1067

Provider Business Practice Location Address
First Line	:	4605 OLEANDER DR
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29577-5739
Country	:	US
Telephone Number	:	843-554-5300
Fax Number	:	843-554-1067

Authorized Official
Title or Position	:	INS. COORD.
Name	:	SHARON DIBENEDETTO
Credential	:
Telephone Number	:	843-554-5300

Provider Enumeration Date	:	04/16/2007
Last Update Date	:	08/22/2020

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