MEDICARE: NIKODEM DENTAL HOLDINGS, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1912651423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NIKODEM DENTAL HOLDINGS, INC.

Provider Business Mailing Address
First Line	:	6220 S LINDBERGH BLVD STE 101
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63123-7839
Country	:	US
Telephone Number	:	314-732-4591
Fax Number	:

Provider Business Practice Location Address
First Line	:	2380 N TRUMAN BLVD
Second Line	:
City	:	CRYSTAL CITY
State	:	MO
Zip	:	63019-1037
Country	:	US
Telephone Number	:	636-937-9193
Fax Number	:

Authorized Official
Title or Position	:	AR SPECIALIST
Name	:	HANNAH MEEKS
Credential	:
Telephone Number	:	314-732-4591

Provider Enumeration Date	:	02/04/2022
Last Update Date	:	02/04/2022

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