Nicole Marie Sudholt, D.M.D.

Primary specialty

DentistTaxonomy code 122300000X

License

019028323 Issued in IL

Practice address

843 W Glen Ave
Peoria, IL 61614-4834

Phone

(309) 691-9421

NPI assigned

Apr 20, 2011

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: No
• Hospice: Yes

Green means eligible to order or refer.

Opted out of Medicare

Yes, effective Mar 2, 2016 through Mar 2, 2028

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Donlan Dental Group

  • General Practice Dentistry
  • Peoria, IL
  • NPI 1306902499
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1303257600000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1303257600000",
    "number": "1184915431",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "843 W GLEN AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616144834",
            "telephone_number": "309-691-9421"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "843 W GLEN AVE",
            "city": "PEORIA",
            "state": "IL",
            "postal_code": "616144834",
            "telephone_number": "309-691-9421"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "SUDHOLT",
        "first_name": "NICOLE",
        "middle_name": "MARIE",
        "name_prefix": "Dr.",
        "credential": "D.M.D.",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2011-04-20",
        "last_updated": "2011-04-20",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "122300000X",
            "taxonomy_group": "",
            "desc": "Dentist",
            "state": "IL",
            "license": "019028323",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Debra Littleton Sturm, PT
• Ronald J Suarez, O.D.
• Bhuvaneswari Subramanian
• Tamarra Lynn Subyantoro, APN
• Eric Thomas Sudholt, D.M.D.
• Daniel Jack Sudrzynski, DO
• Chasity C Suggs, PMHNP-BC
• Thomas Hyung Jun Suh, DO
• Stephanie Ann Sullivan, D.N.P., C.R.N.A.
• Fletcher Summa, MD

• Dentist in Peoria, IL
• Providers in Peoria, IL by specialty
• Dentist in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 20, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.