Provider Demographics
NPI:1053400309
Name:NICKOLES, ELEISHA JEAN (DDS)
Entity type:Individual
Prefix:DR
First Name:ELEISHA
Middle Name:JEAN
Last Name:NICKOLES
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 NATIONAL RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-5706
Mailing Address - Country:US
Mailing Address - Phone:304-242-8600
Mailing Address - Fax:304-242-8665
Practice Address - Street 1:1320 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003-5706
Practice Address - Country:US
Practice Address - Phone:304-242-8600
Practice Address - Fax:304-242-8665
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36691223G0001X
OH30-022488122300000X
PADS0365091223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist