MEDICARE: HEIDI NICHOLS-JOHNSON, DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	1963	ND

General Provider Information

NPI Number	:	1447658950
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEIDI NICHOLS-JOHNSON, DDS

Provider Business Mailing Address
First Line	:	4900 OTTAWA ST
Second Line	:	SUITE 200
City	:	BISMARCK
State	:	ND
Zip	:	58503-6154
Country	:	US
Telephone Number	:	701-751-7510
Fax Number	:

Provider Business Practice Location Address
First Line	:	4900 OTTAWA ST
Second Line	:	SUITE 200
City	:	BISMARCK
State	:	ND
Zip	:	58503-6154
Country	:	US
Telephone Number	:	701-751-7510
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	HEIDI NICHOLS-JOHNSON
Credential	:	D.D.S.
Telephone Number	:	701-751-7510

Provider Enumeration Date	:	12/16/2014
Last Update Date	:	12/16/2014

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