Healthcare Provider Details

I. General information

NPI: 1821586793
Provider Name (Legal Business Name): NICHOLAS JOHN LEDDERHOF BSCH, DDS, MSC, FRCD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1930 ALCOA HWY. MEDICAL BUILDING A, SUITE 335
KNOXVILLE TN
37920-1514
US

IV. Provider business mailing address

1930 ALCOA HWY. MEDICAL BUILDING A, SUITE 335
KNOXVILLE TN
37920-1514
US

V. Phone/Fax

Practice location:
  • Phone: 865-305-9022
  • Fax: 865-305-9026
Mailing address:
  • Phone: 865-305-9022
  • Fax: 865-305-9026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number88428
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: