1013065796 NPI number — DR. TIKY KYTASHA SWAIN DDS

Table of content: DR. TIKY KYTASHA SWAIN DDS (NPI 1013065796)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013065796 NPI number — DR. TIKY KYTASHA SWAIN DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SWAIN
Provider First Name:
TIKY
Provider Middle Name:
KYTASHA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013065796
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/23/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8420 UNIVERSITY EXEC PARK DR
Provider Second Line Business Mailing Address:
SUITE 805
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28262-1344
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-594-9250
Provider Business Mailing Address Fax Number:
704-594-9410

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8420 UNIVERSITY EXEC PARK DR
Provider Second Line Business Practice Location Address:
SUITE 805
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28262-1344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-594-9250
Provider Business Practice Location Address Fax Number:
704-594-9410
Provider Enumeration Date:
01/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223D0001X , with the licence number:  8225 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223G0001X , with the licence number: 8225 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5904063 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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