Provider Demographics
NPI:1326504655
Name:NIKODEM DENTAL HOLDINGS
Entity Type:Organization
Organization Name:NIKODEM DENTAL HOLDINGS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:G
Authorized Official - Last Name:NIKODEM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:314-732-4591
Mailing Address - Street 1:4337 BUTLER HILL RD SUITE L
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63128
Mailing Address - Country:US
Mailing Address - Phone:314-732-4591
Mailing Address - Fax:314-200-9691
Practice Address - Street 1:4337 BUTLER HILL RD SUITE G
Practice Address - Street 2:
Practice Address - City:ST LOUIS MO
Practice Address - State:MO
Practice Address - Zip Code:63128
Practice Address - Country:US
Practice Address - Phone:314-892-2000
Practice Address - Fax:314-892-4550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NIKODEM DENTAL HOLDINGS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-02-12
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty