Healthcare Provider Details

I. General information

NPI: 1982174744
Provider Name (Legal Business Name): MARIA GABRIELA TIBAVINSKY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MARIA GABRIELA TIBAVINSKY BERNAL

II. Dates (important events)

Enumeration Date: 12/04/2018
Last Update Date: 01/25/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1667 LEXINGTON AVE
NEW YORK NY
10029-4962
US

IV. Provider business mailing address

60 CHURCH ST
NEW ROCHELLE NY
10805-3204
US

V. Phone/Fax

Practice location:
  • Phone: 212-289-4131
  • Fax:
Mailing address:
  • Phone: 678-548-0959
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDN015657
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number060774
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: