Healthcare Provider Details

I. General information

NPI: 1083991053
Provider Name (Legal Business Name): DANIEL PATRICK TIBBETTS D.M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2011
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 S INDEPENDENCE MALL E SUITE 610
PHILADELPHIA PA
19106-2515
US

IV. Provider business mailing address

611 WOODCREST AVE
ARDMORE PA
19003-1919
US

V. Phone/Fax

Practice location:
  • Phone: 215-238-0800
  • Fax:
Mailing address:
  • Phone: 302-545-9444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS039118
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: