Provider Demographics
NPI:1679258263
Name:WILSDORF, NICHOLAS JON (DDS)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JON
Last Name:WILSDORF
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 1:818 OAK KNOLL RD
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-4714
Mailing Address - Country:US
Mailing Address - Phone:573-201-4732
Mailing Address - Fax:
Practice Address - Street 1:2653 LOCUST ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63103-1411
Practice Address - Country:US
Practice Address - Phone:314-645-6451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023023194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist