Provider Demographics
NPI:1366998163
Name:CHARLES A. NICKOU, D.M.D LLC
Entity type:Organization
Organization Name:CHARLES A. NICKOU, D.M.D LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:NICKOU
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:978-462-9643
Mailing Address - Street 1:16 HARRIS STREET
Mailing Address - Street 2:
Mailing Address - City:NEWBURYPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01950
Mailing Address - Country:US
Mailing Address - Phone:978-462-9643
Mailing Address - Fax:978-462-6167
Practice Address - Street 1:16 HARRIS STREET
Practice Address - Street 2:
Practice Address - City:NEWBURYPORT
Practice Address - State:MA
Practice Address - Zip Code:01950
Practice Address - Country:US
Practice Address - Phone:978-462-9643
Practice Address - Fax:978-462-6167
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA15915122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA15915OtherDENTAL LICENSE