Provider Demographics
NPI:1821586793
Name:LEDDERHOF, NICHOLAS JOHN (BSCH, DDS, MSC, FRCD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JOHN
Last Name:LEDDERHOF
Suffix:
Gender:M
Credentials:BSCH, DDS, MSC, FRCD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 ALCOA HWY. MEDICAL BUILDING A, SUITE 335
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1514
Mailing Address - Country:US
Mailing Address - Phone:865-305-9022
Mailing Address - Fax:865-305-9026
Practice Address - Street 1:1930 ALCOA HWY. MEDICAL BUILDING A, SUITE 335
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1514
Practice Address - Country:US
Practice Address - Phone:865-305-9022
Practice Address - Fax:865-305-9026
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2018-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
ZZ88428204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program