Healthcare Provider Details

I. General information

NPI: 1003139700
Provider Name (Legal Business Name): DEAN TIBORIS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 06/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5021 WASHINGTON RD
KENOSHA WI
53144-4292
US

IV. Provider business mailing address

5021 WASHINGTON RD
KENOSHA WI
53144-4292
US

V. Phone/Fax

Practice location:
  • Phone: 262-654-6770
  • Fax: 262-654-6727
Mailing address:
  • Phone: 262-654-6770
  • Fax: 262-654-6727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number7210-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: