Healthcare Provider Details

I. General information

NPI: 1578219291
Provider Name (Legal Business Name): NICHOLAS KADDIS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W PIERSON RD
FLINT MI
48504-6802
US

IV. Provider business mailing address

1936 MAPLEWOOD AVE
BLOOMFIELD HILLS MI
48302-0209
US

V. Phone/Fax

Practice location:
  • Phone: 810-789-5880
  • Fax:
Mailing address:
  • Phone: 248-535-6287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number22164130600
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901601388
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: