MEDICARE: DR. NICOL LISA GINDORFF 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	1223G0001X	General Practice Dentistry	D12134	MN
2	122300000X	Dentist	08884	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811059355
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOL LISA GINDORFF DDS

Provider Business Mailing Address
First Line	:	525 W CHERRY ST
Second Line	:
City	:	NORTH LIBERTY
State	:	IA
Zip	:	52317-9797
Country	:	US
Telephone Number	:	319-621-1507
Fax Number	:

Provider Business Practice Location Address
First Line	:	525 W CHERRY ST
Second Line	:
City	:	NORTH LIBERTY
State	:	IA
Zip	:	52317-9797
Country	:	US
Telephone Number	:	319-621-1507
Fax Number	:

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

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	12/30/2019

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