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General NPI Number Information
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NPI Number | 1790845725
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Entity Type | Individual
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Provider Name | ROBERT NIDEA
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Gender | Male
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Dates
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Enumeration Date | 12/11/2006
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Last Update Date | 08/16/2016
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Provider Practice Location Address
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Address Line | 16280 PRINCE DR
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City | SOUTH HOLLAND
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State | IL
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Zip | 60473-3233
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Country | US
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Telephone | 708-225-1866
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Fax |
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Provider Business Mailing Address
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Address Line | 733 S HILLSIDE AVE
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City | ELMHURST
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State | IL
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Zip | 60126-4719
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Country | US
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Telephone | 210-845-5879
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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 | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 22529
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 019-022446
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License Number State | IL
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