Healthcare Provider Details

I. General information

NPI: 1033863535
Provider Name (Legal Business Name): NIKODEM DENTAL HOLDINGS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2022
Last Update Date: 02/04/2022
Certification Date: 02/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4337 BUTLER HILL RD STE G
SAINT LOUIS MO
63128-3735
US

IV. Provider business mailing address

6220 S LINDBERGH BLVD STE 101
SAINT LOUIS MO
63123-7839
US

V. Phone/Fax

Practice location:
  • Phone: 314-892-2000
  • Fax:
Mailing address:
  • Phone: 314-732-4591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: HANNAH MEEKS
Title or Position: AR SPECIALIST
Credential:
Phone: 618-977-6931