Healthcare Provider Details

I. General information

NPI: 1548462526
Provider Name (Legal Business Name): NICAS YIANNIAS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5943 CENTRAL AVE
PORTAGE IN
46368-2946
US

IV. Provider business mailing address

5943 CENTRAL AVE
PORTAGE IN
46368-2946
US

V. Phone/Fax

Practice location:
  • Phone: 219-762-9567
  • Fax: 219-762-8842
Mailing address:
  • Phone: 312-375-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number019-025967
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number12011372A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: