Provider Demographics
NPI:1275656480
Name:STEPHEN G. NIKODEM DDS MS PC
Entity Type:Organization
Organization Name:STEPHEN G. NIKODEM DDS MS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:GERARD
Authorized Official - Last Name:NIKODEM
Authorized Official - Suffix:
Authorized Official - Credentials:DDSMS
Authorized Official - Phone:314-894-1311
Mailing Address - Street 1:4116 VON TALGE RD
Mailing Address - Street 2:STE A
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128-1957
Mailing Address - Country:US
Mailing Address - Phone:314-894-1311
Mailing Address - Fax:314-894-0710
Practice Address - Street 1:4116 VON TALGE RD
Practice Address - Street 2:STE A
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-1957
Practice Address - Country:US
Practice Address - Phone:314-894-1311
Practice Address - Fax:314-894-0710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MODE0155791223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO=========Medicare UPIN