Provider Demographics
NPI:1164689303
Name:NIKODEM, GERARD PATRICK (DDS)
Entity Type:Individual
Prefix:DR
First Name:GERARD
Middle Name:PATRICK
Last Name:NIKODEM
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1121 W GANNON DR
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028
Mailing Address - Country:US
Mailing Address - Phone:636-937-9133
Mailing Address - Fax:636-937-3227
Practice Address - Street 1:1121 W GANNON DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028
Practice Address - Country:US
Practice Address - Phone:636-937-9133
Practice Address - Fax:636-937-3227
Is Sole Proprietor?:No
Enumeration Date:2008-05-16
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014933122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist