Provider Demographics
NPI:1215481155
Name:KRISTIN F. NICKODEMUS, DDS, PLC
Entity type:Organization
Organization Name:KRISTIN F. NICKODEMUS, DDS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:FRANCINE
Authorized Official - Last Name:NICKODEMUS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:734-769-4121
Mailing Address - Street 1:1795 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5290
Mailing Address - Country:US
Mailing Address - Phone:734-769-4121
Mailing Address - Fax:734-662-4156
Practice Address - Street 1:1795 W STADIUM BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-5290
Practice Address - Country:US
Practice Address - Phone:734-769-4121
Practice Address - Fax:734-662-4156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-09
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010176701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty