Provider Demographics
NPI:1770533531
Name:NICHOLAS H. PSIMOS, DDS, PLC
Entity type:Organization
Organization Name:NICHOLAS H. PSIMOS, DDS, PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICHOLAS
Authorized Official - Middle Name:H
Authorized Official - Last Name:PSIMOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:507-288-0126
Mailing Address - Street 1:1101 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55906-6841
Mailing Address - Country:US
Mailing Address - Phone:507-288-0126
Mailing Address - Fax:507-529-0810
Practice Address - Street 1:1101 N BROADWAY
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55906-6841
Practice Address - Country:US
Practice Address - Phone:507-288-0126
Practice Address - Fax:507-529-0810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN324222600Medicaid
IA08865OtherBCBS IA
MN1B261PSOtherBCBS MN
IA088575Medicaid
MN190000453Medicare ID - Type Unspecified
MN1B261PSOtherBCBS MN
IA190000453Medicare ID - Type Unspecified
IA08865OtherBCBS IA