Healthcare Provider Details

I. General information

NPI: 1912912460
Provider Name (Legal Business Name): DEWEY J TIBERII DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 ELM STREET SUITE 9
SOUTHBRIDGE MA
01550-2693
US

IV. Provider business mailing address

39 ELM STREET SUITE 9
SOUTHBRIDGE MA
01550-2693
US

V. Phone/Fax

Practice location:
  • Phone: 508-765-0687
  • Fax: 508-765-2818
Mailing address:
  • Phone: 508-765-0687
  • Fax: 508-765-2818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number13465
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: