Provider Demographics
NPI:1528131901
Name:NICHOLSON, CORNELIUS ADOLPHUS (DDS)
Entity type:Individual
Prefix:DR
First Name:CORNELIUS
Middle Name:ADOLPHUS
Last Name:NICHOLSON
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 1:2815 S MCCLELLAN ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-5407
Mailing Address - Country:US
Mailing Address - Phone:206-722-5000
Mailing Address - Fax:206-721-1428
Practice Address - Street 1:2815 S MCCLELLAN ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144-5407
Practice Address - Country:US
Practice Address - Phone:206-722-5000
Practice Address - Fax:206-721-1428
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2018-05-02
Deactivation Date:2008-01-30
Deactivation Code:
Reactivation Date:2018-05-02
Provider Licenses
StateLicense IDTaxonomies
WA63791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics