Provider Demographics
NPI:1912903303
Name:NICK, THOMAS JOHN (DDS)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:JOHN
Last Name:NICK
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 1:630 1ST ST
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54403-4851
Mailing Address - Country:US
Mailing Address - Phone:715-842-0314
Mailing Address - Fax:715-842-5565
Practice Address - Street 1:630 1ST ST
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54403-4851
Practice Address - Country:US
Practice Address - Phone:715-842-0314
Practice Address - Fax:715-842-5565
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI811G1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33543300Medicaid