Healthcare Provider Details

I. General information

NPI: 1306541305
Provider Name (Legal Business Name): STEPHEN MARK NIKODEM DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2023
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
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

134 FRONTENAC FRST
SAINT LOUIS MO
63131-3220
US

V. Phone/Fax

Practice location:
  • Phone: 314-894-1311
  • Fax:
Mailing address:
  • Phone: 314-402-1168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2023021406
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: