Basic Information
Provider Information
NPI: 1003139700
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: TIBORIS
FirstName: DEAN
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: DMD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 5021 WASHINGTON RD
Address2:  
City: KENOSHA
State: WI
PostalCode: 531444292
CountryCode: US
TelephoneNumber: 2626546770
FaxNumber: 2626546727
Practice Location
Address1: 5021 WASHINGTON RD
Address2:  
City: KENOSHA
State: WI
PostalCode: 531444292
CountryCode: US
TelephoneNumber: 2626546770
FaxNumber: 2626546727
Other Information
ProviderEnumerationDate: 03/09/2010
LastUpdateDate: 06/10/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
204E00000X7210-15WIY Allopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery 
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


Home