Healthcare Provider Details

I. General information

NPI: 1255892147
Provider Name (Legal Business Name): MARINA TITOV RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 03/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200 LUCILE DR STE 100
LINCOLN NE
68506-6032
US

IV. Provider business mailing address

11066 W HAINES CIR
DENTON NE
68339-9608
US

V. Phone/Fax

Practice location:
  • Phone: 402-483-7631
  • Fax:
Mailing address:
  • Phone: 402-613-2154
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number2291
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: