Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0106X | Oral and Maxillofacial Pathology | 023442 | NY |
NPI | 1760400964 |
---|---|
Provider Name | Dr. Joseph J Nicols JR. |
First Address | West Islip, NY 11795-4421 |
Second Address | West Islip, NY 11795-4421 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/07/2006 |
Last Update Date | 08/07/2007 |