Provider Demographics
NPI:1629110085
Name:DRZYCIMSKI, NICHOLAS J (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:J
Last Name:DRZYCIMSKI
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:PO BOX 1823
Mailing Address - Street 2:2727 NORTH 15TH STREET
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-1823
Mailing Address - Country:US
Mailing Address - Phone:515-576-5786
Mailing Address - Fax:515-576-5128
Practice Address - Street 1:2727 N 15TH ST
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-7203
Practice Address - Country:US
Practice Address - Phone:515-576-5786
Practice Address - Fax:515-576-5128
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA65581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA843081OtherUNITED CONCORDIA
IA0500132Medicaid
IA192898OtherDELTA DENTAL