Provider Demographics
NPI:1912006594
Name:VANDERBURG, NIKKO J (DDS)
Entity Type:Individual
Prefix:DR
First Name:NIKKO
Middle Name:J
Last Name:VANDERBURG
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3313 BALTIMORE AVE
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74403-5939
Mailing Address - Country:US
Mailing Address - Phone:405-630-8215
Mailing Address - Fax:918-680-3782
Practice Address - Street 1:1011 HONOR HEIGHTS DR
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-1318
Practice Address - Country:US
Practice Address - Phone:918-680-3781
Practice Address - Fax:918-680-3782
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY053123-1122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist