Provider Demographics
NPI:1679754790
Name:NIKODEM AND HILL FAMILY DENTAL AND ORTHO
Entity Type:Organization
Organization Name:NIKODEM AND HILL FAMILY DENTAL AND ORTHO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:DR
Authorized Official - First Name:GERARD
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:NIKODEM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:573-438-2118
Mailing Address - Street 1:200 HEALTHWAY DR STE 1
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63664
Mailing Address - Country:US
Mailing Address - Phone:573-438-2118
Mailing Address - Fax:
Practice Address - Street 1:200 HEALTH WAY DR STE 1
Practice Address - Street 2:
Practice Address - City:POTOSI
Practice Address - State:MO
Practice Address - Zip Code:63664-1447
Practice Address - Country:US
Practice Address - Phone:573-438-2118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NIKODEM AND HILL FAMILY DENTAL AND ORTHO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-16
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO014933122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty