Healthcare Provider Details

I. General information

NPI: 1518085992
Provider Name (Legal Business Name): NIKKI A WARGO DDS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2370 E 37TH AVE
LAKE STATION IN
46405
US

IV. Provider business mailing address

8430 INDIANA ST
MERRILLVILLE IN
46410-6357
US

V. Phone/Fax

Practice location:
  • Phone: 219-962-3000
  • Fax: 219-962-9571
Mailing address:
  • Phone: 219-756-6214
  • Fax: 219-756-6214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number12010645A
License Number StateIN

VIII. Authorized Official

Name: NIKKI ANN WARGO
Title or Position: DDS
Credential: DDS
Phone: 219-962-3000