Provider Demographics
NPI:1447658950
Name:HEIDI NICHOLS-JOHNSON, DDS
Entity type:Organization
Organization Name:HEIDI NICHOLS-JOHNSON, DDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HEIDI
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:701-751-7510
Mailing Address - Street 1:4900 OTTAWA ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58503-6154
Mailing Address - Country:US
Mailing Address - Phone:701-751-7510
Mailing Address - Fax:
Practice Address - Street 1:4900 OTTAWA ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58503-6154
Practice Address - Country:US
Practice Address - Phone:701-751-7510
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1963261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental