Provider Demographics
NPI:1114385044
Name:BARTON TOMBLIN, NICHOLE
Entity Type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:
Last Name:BARTON TOMBLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:OTHELLO
Mailing Address - State:WA
Mailing Address - Zip Code:99344-1846
Mailing Address - Country:US
Mailing Address - Phone:509-488-5256
Mailing Address - Fax:509-488-9939
Practice Address - Street 1:1515 E COLUMBIA ST
Practice Address - Street 2:DENTAL DEPARTMENT
Practice Address - City:OTHELLO
Practice Address - State:WA
Practice Address - Zip Code:99344-9934
Practice Address - Country:US
Practice Address - Phone:509-488-5256
Practice Address - Fax:509-488-9939
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-06
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE60708382122300000X
WADERE.RR.60595360390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2072503Medicaid