Provider Demographics
NPI:1285782045
Name:MCKIBBINS, SANTA MARIA (DDS)
Entity type:Individual
Prefix:DR
First Name:SANTA
Middle Name:MARIA
Last Name:MCKIBBINS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1413 W NC HIGHWAY 54
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-5507
Mailing Address - Country:US
Mailing Address - Phone:919-493-6860
Mailing Address - Fax:919-493-6869
Practice Address - Street 1:1413 W NC HIGHWAY 54
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-5507
Practice Address - Country:US
Practice Address - Phone:919-493-6860
Practice Address - Fax:919-493-6869
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2012-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC69351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC9002ROtherHEALTHCHOICE
1633202OtherUNITED CONCORDIA
NC799002RMedicaid