1053418400 NPI number — HEIDI M. NICHOLS-JOHNSON DDS

Table of content: HEIDI M. NICHOLS-JOHNSON DDS (NPI 1053418400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053418400 NPI number — HEIDI M. NICHOLS-JOHNSON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS-JOHNSON
Provider First Name:
HEIDI
Provider Middle Name:
M.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053418400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1929 N. WASHINGTON ST.
Provider Second Line Business Mailing Address:
PO BOX 7039
Provider Business Mailing Address City Name:
BISMARCK
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58507-7039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-258-7900
Provider Business Mailing Address Fax Number:
701-250-0557

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1929 N. WASHINGTON ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BISMARCK
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58507-7039
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-258-7900
Provider Business Practice Location Address Fax Number:
701-250-0557
Provider Enumeration Date:
09/20/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  1963 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)