Healthcare Provider Details

I. General information

NPI: 1457618498
Provider Name (Legal Business Name): IGOR N TIKHONOV DDS, MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2012
Last Update Date: 07/10/2024
Certification Date: 07/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S DENTON TAP RD STE 300
COPPELL TX
75019-4533
US

IV. Provider business mailing address

600 S DENTON TAP RD STE 300
COPPELL TX
75019-4533
US

V. Phone/Fax

Practice location:
  • Phone: 206-719-8396
  • Fax: 972-744-3305
Mailing address:
  • Phone: 206-719-8396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number32448
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: