Provider Demographics
NPI:1386104685
Name:NICHOLS OUTPATIENT FACIAL SURGERY
Entity type:Organization
Organization Name:NICHOLS OUTPATIENT FACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:R
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:601-420-3223
Mailing Address - Street 1:266 KATHERINE DR
Mailing Address - Street 2:
Mailing Address - City:FLOWOOD
Mailing Address - State:MS
Mailing Address - Zip Code:39232-8801
Mailing Address - Country:US
Mailing Address - Phone:601-420-3223
Mailing Address - Fax:601-420-3054
Practice Address - Street 1:266 KATHERINE DR
Practice Address - Street 2:
Practice Address - City:FLOWOOD
Practice Address - State:MS
Practice Address - Zip Code:39232-8801
Practice Address - Country:US
Practice Address - Phone:601-420-3223
Practice Address - Fax:601-420-3054
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ORAL AND FACIAL SURGERY OF MISSISSIPPI
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-22
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical