Provider Demographics
NPI:1285807081
Name:NICHOLS, MATTHEW LEE
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 JENNINGS CIR
Mailing Address - Street 2:
Mailing Address - City:TULLAHOMA
Mailing Address - State:TN
Mailing Address - Zip Code:37388-8853
Mailing Address - Country:US
Mailing Address - Phone:931-581-8188
Mailing Address - Fax:
Practice Address - Street 1:1425 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2517
Practice Address - Country:US
Practice Address - Phone:931-954-5244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-12
Last Update Date:2012-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS00000091361223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No122300000XDental ProvidersDentist