MEDICARE: DR. DALE ARTHUR NICHOLS 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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	1097	AK
2	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	5370-015	WI
3	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	34698	TX

General Provider Information

NPI Number	:	1992755078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DALE ARTHUR NICHOLS D.D.S.

Provider Business Mailing Address
First Line	:	UNIT 28038
Second Line	:
City	:	APO
State	:	AE
Zip	:	09112-8038
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1811 ARMY BLVD BLDG 2018
Second Line	:
City	:	FORT SAM HOUSTON
State	:	TX
Zip	:	78234-2686
Country	:	US
Telephone Number	:	512-665-7744
Fax Number	:

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

Provider Enumeration Date	:	05/11/2006
Last Update Date	:	10/31/2022

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