Provider Demographics
NPI:1215181284
Name:JOHNNIDIS, NICHOLAS JOHN (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:JOHNNIDIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WIER LANE
Mailing Address - Street 2:
Mailing Address - City:LOCUST VALLEY-NASSAU COUNTY
Mailing Address - State:NY
Mailing Address - Zip Code:11560
Mailing Address - Country:US
Mailing Address - Phone:516-759-2288
Mailing Address - Fax:516-759-0993
Practice Address - Street 1:5 WIER LANE
Practice Address - Street 2:LOCUST VALLEY
Practice Address - City:NASSAU COUNTY, LONG ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11560
Practice Address - Country:US
Practice Address - Phone:516-759-2288
Practice Address - Fax:516-759-0993
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0342401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice