Healthcare Provider Details

I. General information

NPI: 1700909991
Provider Name (Legal Business Name): STEPHEN GERARD NIKODEM DDS,.MS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
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 NumberDE-015579
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: