Provider Demographics
NPI:1063132470
Name:CASSIDY, NIKOLAUS JOSEPH (DMD)
Entity type:Individual
Prefix:
First Name:NIKOLAUS
Middle Name:JOSEPH
Last Name:CASSIDY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7901 HENRY AVE APT C302
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19128-6075
Mailing Address - Country:US
Mailing Address - Phone:610-416-5672
Mailing Address - Fax:
Practice Address - Street 1:2370 YORK RD STE D1
Practice Address - Street 2:
Practice Address - City:JAMISON
Practice Address - State:PA
Practice Address - Zip Code:18929-1031
Practice Address - Country:US
Practice Address - Phone:215-343-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-29
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS043776122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist