Provider Demographics
NPI:1841495041
Name:H.A. NICHOLSON III
Entity type:Organization
Organization Name:H.A. NICHOLSON III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HOWELL
Authorized Official - Middle Name:ANDERSON
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:910-762-4459
Mailing Address - Street 1:1631 DOCTORS CIR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7405
Mailing Address - Country:US
Mailing Address - Phone:910-762-4459
Mailing Address - Fax:910-762-4413
Practice Address - Street 1:1631 DOCTORS CIR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7405
Practice Address - Country:US
Practice Address - Phone:910-762-4459
Practice Address - Fax:910-762-4413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3209122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89963979Medicaid