Provider Demographics
NPI:1205029071
Name:MARCUS, NICHOLAS JAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JAY
Last Name:MARCUS
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 1:400 24TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:WILLMAR
Mailing Address - State:MN
Mailing Address - Zip Code:56201-5326
Mailing Address - Country:US
Mailing Address - Phone:320-235-9363
Mailing Address - Fax:320-403-5226
Practice Address - Street 1:400 24TH AVE SE
Practice Address - Street 2:
Practice Address - City:WILLMAR
Practice Address - State:MN
Practice Address - Zip Code:56201-5326
Practice Address - Country:US
Practice Address - Phone:320-235-9363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND12464122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist