Provider Demographics
NPI:1013171156
Name:WEISS, NICKOLAUS M (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICKOLAUS
Middle Name:M
Last Name:WEISS
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 1:1842 STEVEN AVE
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:IN
Mailing Address - Zip Code:47421-3500
Mailing Address - Country:US
Mailing Address - Phone:262-227-1348
Mailing Address - Fax:
Practice Address - Street 1:1842 STEVEN AVE
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:IN
Practice Address - Zip Code:47421-3500
Practice Address - Country:US
Practice Address - Phone:812-279-9767
Practice Address - Fax:812-279-5971
Is Sole Proprietor?:No
Enumeration Date:2008-07-17
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIWI6335122300000X
VA04014121481223G0001X
IN12011545A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice