Healthcare Provider Details

I. General information

NPI: 1811059355
Provider Name (Legal Business Name): NICOL LISA GINDORFF DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 12/30/2019
Certification Date: 12/30/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 W CHERRY ST
NORTH LIBERTY IA
52317-9797
US

IV. Provider business mailing address

525 W CHERRY ST
NORTH LIBERTY IA
52317-9797
US

V. Phone/Fax

Practice location:
  • Phone: 319-621-1507
  • Fax:
Mailing address:
  • Phone: 319-621-1507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number08884
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberD12134
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: