Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 122300000X | Dentist | 100587 | CA |
NPI | 1003367293 |
---|---|
Provider Name | Dr. Justin William Nichols |
First Address | Diamond Bar, CA 91765-3351 |
Second Address | Seattle, WA 98108-1532 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 22/10/2016 |
Last Update Date | 22/10/2016 |