Provider Demographics
NPI:1396090320
Name:BARTH, NICHOLAS (DDS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BARTH
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 1:19606 SR 20 W
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-3916
Mailing Address - Country:US
Mailing Address - Phone:850-674-5502
Mailing Address - Fax:850-674-9790
Practice Address - Street 1:19606 SR 20 W
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-3916
Practice Address - Country:US
Practice Address - Phone:850-674-5502
Practice Address - Fax:850-674-9790
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 19827122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLDN 19827OtherSTATE OF FLORIDA MEDICAL LICENSE