MEDICARE: TIBA DENTAL, PC

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	122300000X	Dentist	049557	NY

General Provider Information

NPI Number	:	1861874901
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TIBA DENTAL, PC

Provider Business Mailing Address
First Line	:	466 78TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3404
Country	:	US
Telephone Number	:	718-491-6585
Fax Number	:	718-491-6586

Provider Business Practice Location Address
First Line	:	466 78TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11209-3404
Country	:	US
Telephone Number	:	718-491-6585
Fax Number	:	718-491-6586

Authorized Official
Title or Position	:	D.D.S.
Name	:	DR. ABDELHAMED A TAMARA
Credential	:
Telephone Number	:	718-491-6585

Provider Enumeration Date	:	06/25/2015
Last Update Date	:	06/25/2015

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