Provider Demographics
NPI:1518526763
Name:ECONOMOS, NICHOLAS STEPHEN (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:STEPHEN
Last Name:ECONOMOS
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 1:1233 63RD ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50311-1943
Mailing Address - Country:US
Mailing Address - Phone:515-277-6358
Mailing Address - Fax:
Practice Address - Street 1:1233 63RD ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50311-1943
Practice Address - Country:US
Practice Address - Phone:515-277-6358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096571223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice