Healthcare Provider Details

I. General information

NPI: 1477487650
Provider Name (Legal Business Name): JOHN NIKODEM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACK NIKODEM DDS

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 W GANNON DR
FESTUS MO
63028-2602
US

IV. Provider business mailing address

1800 S BRENTWOOD BLVD APT 611
SAINT LOUIS MO
63144-1846
US

V. Phone/Fax

Practice location:
  • Phone: 636-937-9133
  • Fax:
Mailing address:
  • Phone: 314-954-3342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2026023637
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: