Provider Demographics
NPI:1528027851
Name:IVES, NICHOLAS DANE (DMD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:DANE
Last Name:IVES
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 1:3871 UTAH PL
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63116-4832
Mailing Address - Country:US
Mailing Address - Phone:212-732-7400
Mailing Address - Fax:212-732-0267
Practice Address - Street 1:3430 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-5006
Practice Address - Country:US
Practice Address - Phone:212-732-7400
Practice Address - Fax:212-732-0267
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0523081223G0001X
IL190269931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02677425Medicaid