MEDICARE: DR. THOMAS JOHN NICK D.D.S.

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	811G	WI

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

General Provider Information

NPI Number	:	1912903303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. THOMAS JOHN NICK D.D.S.

Provider Business Mailing Address
First Line	:	630 1ST ST
Second Line	:
City	:	WAUSAU
State	:	WI
Zip	:	54403-4851
Country	:	US
Telephone Number	:	715-842-0314
Fax Number	:	715-842-5565

Provider Business Practice Location Address
First Line	:	630 1ST ST
Second Line	:
City	:	WAUSAU
State	:	WI
Zip	:	54403-4851
Country	:	US
Telephone Number	:	715-842-0314
Fax Number	:	715-842-5565

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	07/08/2007

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