Healthcare Provider Details

I. General information

NPI: 1083681928
Provider Name (Legal Business Name): NICHOLAS H. PSIMOS D.D.S, PLC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 N BROADWAY
ROCHESTER MN
55906-6841
US

IV. Provider business mailing address

1101 N BROADWAY
ROCHESTER MN
55906-6841
US

V. Phone/Fax

Practice location:
  • Phone: 507-288-0126
  • Fax: 507-529-0810
Mailing address:
  • Phone: 507-288-0126
  • Fax: 507-529-0810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD10595
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: