Provider Demographics
NPI:1083681928
Name:PSIMOS, NICHOLAS H (DDS, PLC)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:H
Last Name:PSIMOS
Suffix:
Gender:M
Credentials:DDS, PLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-6841
Mailing Address - Country:US
Mailing Address - Phone:507-288-0126
Mailing Address - Fax:507-529-0810
Practice Address - Street 1:1101 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-6841
Practice Address - Country:US
Practice Address - Phone:507-288-0126
Practice Address - Fax:507-529-0810
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-28
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND105951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0088575Medicaid
MN1B261PSOtherBCBS PROVIDER ID
MN324222600Medicaid
MN324222600Medicaid
MNT91003Medicare UPIN