MEDICARE: RAYMOND GERARD NIKODEM 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	122300000X	Dentist	014792	MO

General Provider Information

NPI Number	:	1740317098
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAYMOND GERARD NIKODEM DDS

Provider Business Mailing Address
First Line	:	4337 BUTLER HILL RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-3735
Country	:	US
Telephone Number	:	314-892-2000
Fax Number	:	314-892-4550

Provider Business Practice Location Address
First Line	:	4337 BUTLER HILL RD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63128-3735
Country	:	US
Telephone Number	:	314-892-2000
Fax Number	:	314-892-4550

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/27/2007
Last Update Date	:	07/08/2007

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