Healthcare Provider Details

I. General information

NPI: 1275656480
Provider Name (Legal Business Name): STEPHEN G. NIKODEM DDS MS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4116 VON TALGE RD STE A
SAINT LOUIS MO
63128-1957
US

IV. Provider business mailing address

4116 VON TALGE RD STE A
SAINT LOUIS MO
63128-1957
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-1311
  • Fax: 314-894-0710
Mailing address:
  • Phone: 314-894-1311
  • Fax: 314-894-0710

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDE015579
License Number StateMO

VIII. Authorized Official

Name: DR. STEPHEN GERARD NIKODEM
Title or Position: ORTHODONTIST
Credential: DDSMS
Phone: 314-894-1311