Provider Demographics
NPI:1871992701
Name:FELLER, NICHOLAS STEPHEN (DMD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:STEPHEN
Last Name:FELLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 RICKARD RD STE B
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704-6387
Mailing Address - Country:US
Mailing Address - Phone:217-787-8788
Mailing Address - Fax:217-787-0178
Practice Address - Street 1:1140 RICKARD RD STE B
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-6387
Practice Address - Country:US
Practice Address - Phone:217-787-8788
Practice Address - Fax:217-787-0178
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0300131223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice