Provider Demographics
NPI:1649212127
Name:NANNFELDT, NICKY WAYNE (DDS)
Entity Type:Individual
Prefix:MR
First Name:NICKY
Middle Name:WAYNE
Last Name:NANNFELDT
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 1:1600 NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1609
Mailing Address - Country:US
Mailing Address - Phone:269-983-1812
Mailing Address - Fax:269-983-3282
Practice Address - Street 1:1600 NILES AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1609
Practice Address - Country:US
Practice Address - Phone:269-983-1812
Practice Address - Fax:269-983-3282
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI10461122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist