Provider Demographics
NPI:1154355741
Name:PAVLOV, NICK (DDS)
Entity type:Individual
Prefix:DR
First Name:NICK
Middle Name:
Last Name:PAVLOV
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 NAUTILUS ST
Mailing Address - Street 2:SUITE 212
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-5969
Mailing Address - Country:US
Mailing Address - Phone:858-459-5591
Mailing Address - Fax:858-459-4242
Practice Address - Street 1:706 TOWNSITE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-4502
Practice Address - Country:US
Practice Address - Phone:760-724-4392
Practice Address - Fax:760-724-4392
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA440551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice