Healthcare Provider Details

I. General information

NPI: 1861874901
Provider Name (Legal Business Name): TIBA DENTAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2015
Last Update Date: 06/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

466 78TH ST
BROOKLYN NY
11209-3404
US

IV. Provider business mailing address

466 78TH ST
BROOKLYN NY
11209-3404
US

V. Phone/Fax

Practice location:
  • Phone: 718-491-6585
  • Fax: 718-491-6586
Mailing address:
  • Phone: 718-491-6585
  • Fax: 718-491-6586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number049557
License Number StateNY

VIII. Authorized Official

Name: DR. ABDELHAMED A TAMARA
Title or Position: D.D.S.
Credential:
Phone: 718-491-6585