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General NPI Number Information
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NPI Number | 1154175818
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Entity Type | Individual
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Provider Name | NIKOLAS KENNETH DIEDERICH DMD
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Gender | Male
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Dates
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Enumeration Date | 04/17/2024
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Last Update Date | 07/22/2025
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Provider Practice Location Address
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Address Line | 668 E 12225 S STE 101
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City | DRAPER
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State | UT
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Zip | 84020-7310
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Country | US
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Telephone | 801-762-8920
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Fax |
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Provider Business Mailing Address
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Address Line | 7115 S 2155 E
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City | COTTONWOOD HEIGHTS
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State | UT
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Zip | 84121-3832
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Country | US
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Telephone | 801-931-8322
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 13909577-9923
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License Number State | UT
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