Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204E00000X | Oral & Maxillofacial Surgeon | 604 | CO |
NPI | 1407834120 |
---|---|
Provider Name | Dr. Kenton C Nicholas |
First Address | Greeley, CO 80631-5114 |
Second Address | Greeley, CO 80631-5114 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/01/2006 |
Last Update Date | 02/05/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02006047 | (05) | CO |
P00944805 | MEDICARE RAILROAD CARRIER PTAN (01) | CO |
T60254 | (02) | CO |