Provider Demographics
NPI:1629777636
Name:SOUTHICHACK, NINTA
Entity Type:Individual
Prefix:
First Name:NINTA
Middle Name:
Last Name:SOUTHICHACK
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 1:1400 TOPLEA DR
Mailing Address - Street 2:
Mailing Address - City:EULESS
Mailing Address - State:TX
Mailing Address - Zip Code:76040-4976
Mailing Address - Country:US
Mailing Address - Phone:682-203-8530
Mailing Address - Fax:
Practice Address - Street 1:1607 E MCKINNEY ST STE 100
Practice Address - Street 2:
Practice Address - City:DENTON
Practice Address - State:TX
Practice Address - Zip Code:76209-4579
Practice Address - Country:US
Practice Address - Phone:940-387-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-28
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40137122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist