Healthcare Provider Details

I. General information

NPI: 1174551329
Provider Name (Legal Business Name): JEFFREY J. TIBBS D.D.S., P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3455 HEALY DR
WINSTON-SALEM NC
27103-1442
US

IV. Provider business mailing address

3455 HEALY DR
WINSTON-SALEM NC
27103-1442
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-7477
  • Fax: 336-765-7804
Mailing address:
  • Phone: 336-765-7477
  • Fax: 336-765-7804

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number5856
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: