Individual
DR. CHARLES THOMAS NUCKOLS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
D.M.D.
Contact information
Practice address
627 EASTWOOD AVE, BOWLING GREEN, KY 42103-1688
(270) 843-4341
(270) 746-9551
Mailing address
627 EASTWOOD AVE, BOWLING GREEN, KY 42103-1688
(270) 843-4341
(270) 746-9551
Taxonomy
Speciality
Code
Description
License number
State
1223S0112X
Oral and Maxillofacial Surgery (Dentist)
Primary
3399
KY
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
3399
KY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000212083
ANTHEM PROVIDER ID
KY
01
—
1069982
PASSPORT HEALTH ID PIN
KY
01
—
1115671
PASSPORT GROUP PIN
KY
05
—
60033990
—
KY
01
—
6389
DORAL DENTAL ID
KY
05
—
64033996
—
KY
Enumeration date
07/27/2006
Last updated
01/10/2008
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