Provider Demographics
NPI:1740317007
Name:NIKODEM, KEITH ANDREW (DDS)
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:ANDREW
Last Name:NIKODEM
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 1:4420 LEMAY FERRY RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-1758
Mailing Address - Country:US
Mailing Address - Phone:314-487-1515
Mailing Address - Fax:314-416-8322
Practice Address - Street 1:4420 LEMAY FERRY RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63129-1758
Practice Address - Country:US
Practice Address - Phone:314-487-1515
Practice Address - Fax:314-416-8322
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001024027122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist