Individual
DR. KENTON C NICHOLAS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DDS
Contact information
Practice address
1900 16TH ST, GREELEY, CO 80631-5114
(970) 350-2458
(970) 392-4715
Mailing address
1900 16TH ST, GREELEY, CO 80631-5114
(970) 350-2458
(970) 392-4715
Taxonomy
Speciality
Code
Description
License number
State
204E00000X
Oral & Maxillofacial Surgery (D.M.D.)
Primary
604
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
02006047
—
CO
01
—
P00944805
MEDICARE RAILROAD CARRIER PTAN
CO
Enumeration date
01/03/2006
Last updated
05/02/2012
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