Healthcare Provider Details

I. General information

NPI: 1134644149
Provider Name (Legal Business Name): TIBBITTS MENIFEE DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27701 SCOTT RD STE 107
MENIFEE CA
92584-9434
US

IV. Provider business mailing address

27701 SCOTT RD STE 107
MENIFEE CA
92584-9434
US

V. Phone/Fax

Practice location:
  • Phone: 951-301-6100
  • Fax: 951-301-3669
Mailing address:
  • Phone: 951-301-6100
  • Fax: 951-301-3669

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number53656
License Number StateCA

VIII. Authorized Official

Name: VALERIE ANN ROGERS
Title or Position: OFFICE ASSISTANT
Credential:
Phone: 951-677-5113