Provider Demographics
NPI:1437218419
Name:MIKITKA, DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MIKITKA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9636 BARTLETT CIR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76108-4454
Mailing Address - Country:US
Mailing Address - Phone:817-500-9133
Mailing Address - Fax:
Practice Address - Street 1:9636 BARTLETT CIR
Practice Address - Street 2:SUITE 400
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76108-4454
Practice Address - Country:US
Practice Address - Phone:817-500-9133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX174381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice