Healthcare Provider Details

I. General information

NPI: 1396438636
Provider Name (Legal Business Name): INDIRA TIKHONOVA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2023
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N MAIN ST
TRAVELERS REST SC
29690-1527
US

IV. Provider business mailing address

309 N MAIN ST
TRAVELERS REST SC
29690-1527
US

V. Phone/Fax

Practice location:
  • Phone: 864-610-6188
  • Fax:
Mailing address:
  • Phone: 864-610-6188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number04865
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: