Healthcare Provider Details

I. General information

NPI: 1063137834
Provider Name (Legal Business Name): APIS NIKRODHANOND PHDH, RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: APISCHAYA NIKRODHANOND

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1106 NEAL AVE
JOLIET IL
60433-2548
US

IV. Provider business mailing address

745 W EXCHANGE ST
CRETE IL
60417-2002
US

V. Phone/Fax

Practice location:
  • Phone: 815-727-8670
  • Fax:
Mailing address:
  • Phone: 708-508-0227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code125K00000X
TaxonomyAdvanced Practice Dental Therapist
License Number020.013083
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: