Provider Demographics
NPI:1558392332
Name:FANGMAN, NICHOLAS JOHN (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:FANGMAN
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 1:1406 N US HIGHWAY 71
Mailing Address - Street 2:
Mailing Address - City:CARROLL
Mailing Address - State:IA
Mailing Address - Zip Code:51401-3344
Mailing Address - Country:US
Mailing Address - Phone:712-792-2630
Mailing Address - Fax:712-792-5547
Practice Address - Street 1:1406 N US HIGHWAY 71
Practice Address - Street 2:
Practice Address - City:CARROLL
Practice Address - State:IA
Practice Address - Zip Code:51401-3344
Practice Address - Country:US
Practice Address - Phone:712-792-2630
Practice Address - Fax:712-792-5547
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA07225122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0042820Medicaid