Provider Demographics
NPI:1386255297
Name:SLATER, NICHOLAS WILLARD (DMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:WILLARD
Last Name:SLATER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6963 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85207-8209
Mailing Address - Country:US
Mailing Address - Phone:480-981-3047
Mailing Address - Fax:
Practice Address - Street 1:6963 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85207-8209
Practice Address - Country:US
Practice Address - Phone:480-981-3047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0108261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice