Provider Demographics
NPI:1669631859
Name:BAKKUM, NICHOLAS RYAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:RYAN
Last Name:BAKKUM
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 1:204 2ND AVE NE
Mailing Address - Street 2:
Mailing Address - City:HAZEN
Mailing Address - State:ND
Mailing Address - Zip Code:58545-4420
Mailing Address - Country:US
Mailing Address - Phone:701-748-2730
Mailing Address - Fax:
Practice Address - Street 1:204 2ND AVE NE
Practice Address - Street 2:
Practice Address - City:HAZEN
Practice Address - State:ND
Practice Address - Zip Code:58545-4420
Practice Address - Country:US
Practice Address - Phone:701-748-2730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND20181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice