=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114671997
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MUSSIE SIBHATU DDS, A DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/09/2022
-----------------------------------------------------
Last Update Date | 02/09/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3630 MACARTHUR BLVD
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94619-1328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-530-3317
-----------------------------------------------------
Fax | 510-530-3370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3147 TELEGRAPH AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-3206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-420-1717
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST OWNER
-----------------------------------------------------
Name | DR. MUSSIE SIBHATU
-----------------------------------------------------
Credential | DDS, MS
-----------------------------------------------------
Telephone | 510-520-1533
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------