Provider Demographics
NPI:1407424955
Name:KOSTIUK, NICHOLE (DMD)
Entity type:Individual
Prefix:DR
First Name:NICHOLE
Middle Name:
Last Name:KOSTIUK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9901 BRODIE LN STE 130
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78748-5889
Mailing Address - Country:US
Mailing Address - Phone:737-203-8538
Mailing Address - Fax:
Practice Address - Street 1:9901 BRODIE LN STE 130
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78748-5889
Practice Address - Country:US
Practice Address - Phone:737-203-8538
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX400001223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program