Provider Demographics
NPI:1609613637
Name:NIERENHAUSEN, JACK
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:NIERENHAUSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1815 SUBURBAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4302
Mailing Address - Country:US
Mailing Address - Phone:651-315-8011
Mailing Address - Fax:
Practice Address - Street 1:1815 SUBURBAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-4302
Practice Address - Country:US
Practice Address - Phone:651-315-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-09
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND151511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice