Provider Demographics
NPI:1508396375
Name:NIEKAMP, CASEY N
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:N
Last Name:NIEKAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1849 WENTZVILLE PKWY
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-3896
Mailing Address - Country:US
Mailing Address - Phone:636-639-1720
Mailing Address - Fax:636-639-1935
Practice Address - Street 1:1849 WENTZVILLE PKWY
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-3896
Practice Address - Country:US
Practice Address - Phone:636-639-1720
Practice Address - Fax:636-639-1935
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017019261122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist