Basic Information
| Provider Information | |||||||||
| NPI: | 1528027851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IVES | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | DANE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3871 UTAH PL | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631164832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127327400 | ||||||||
| FaxNumber: | 2127320267 | ||||||||
| Practice Location | |||||||||
| Address1: | 3430 COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | ALTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 620025006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2127327400 | ||||||||
| FaxNumber: | 2127320267 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2006 | ||||||||
| LastUpdateDate: | 05/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 052308 | NY | N | Dental Providers | Dentist | General Practice | 1223G0001X | 19026993 | IL | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 02677425 | 05 | NY | MEDICAID |