MEDICARE: DR. DEAN TIBORIS DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	204E00000X	Oral & Maxillofacial Surgery (D.M.D.)	7210-15	WI

General Provider Information

NPI Number	:	1003139700
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEAN TIBORIS DMD

Provider Business Mailing Address
First Line	:	5021 WASHINGTON RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-4292
Country	:	US
Telephone Number	:	262-654-6770
Fax Number	:	262-654-6727

Provider Business Practice Location Address
First Line	:	5021 WASHINGTON RD
Second Line	:
City	:	KENOSHA
State	:	WI
Zip	:	53144-4292
Country	:	US
Telephone Number	:	262-654-6770
Fax Number	:	262-654-6727

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	06/10/2014

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