Provider Demographics
NPI:1194783308
Name:NICHOLAS, KRISTAN EDWARD (DDS)
Entity type:Individual
Prefix:DR
First Name:KRISTAN
Middle Name:EDWARD
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4154 SECOR RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4230
Mailing Address - Country:US
Mailing Address - Phone:419-475-3494
Mailing Address - Fax:
Practice Address - Street 1:4154 SECOR RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4230
Practice Address - Country:US
Practice Address - Phone:419-475-3494
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.020076122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist