Healthcare Provider Details

I. General information

NPI: 1063512853
Provider Name (Legal Business Name): DR. J MICHAEL TIBERII
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

643 ROUTE 184
GROTON CT
06340
US

IV. Provider business mailing address

19 WHITEHALL LN
MYSTIC CT
06355-1640
US

V. Phone/Fax

Practice location:
  • Phone: 860-445-8569
  • Fax:
Mailing address:
  • Phone: 860-245-0492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number4459
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: