Provider Demographics
NPI:1811059355
Name:GINDORFF, NICOL LISA (DDS)
Entity type:Individual
Prefix:DR
First Name:NICOL
Middle Name:LISA
Last Name:GINDORFF
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 W CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LIBERTY
Mailing Address - State:IA
Mailing Address - Zip Code:52317-9797
Mailing Address - Country:US
Mailing Address - Phone:319-621-1507
Mailing Address - Fax:
Practice Address - Street 1:525 W CHERRY ST
Practice Address - Street 2:
Practice Address - City:NORTH LIBERTY
Practice Address - State:IA
Practice Address - Zip Code:52317-9797
Practice Address - Country:US
Practice Address - Phone:319-621-1507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121341223G0001X
IA08884122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN163445300Medicaid