Provider Demographics
NPI:1255892147
Name:TITOV, MARINA (RDH)
Entity type:Individual
Prefix:
First Name:MARINA
Middle Name:
Last Name:TITOV
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11066 W HAINES CIR
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:NE
Mailing Address - Zip Code:68339-9608
Mailing Address - Country:US
Mailing Address - Phone:402-613-2154
Mailing Address - Fax:
Practice Address - Street 1:4200 LUCILE DR STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-6032
Practice Address - Country:US
Practice Address - Phone:402-483-7631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-25
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE2291124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist