Provider Demographics
NPI:1003139700
Name:TIBORIS, DEAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:DEAN
Middle Name:
Last Name:TIBORIS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5021 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53144-4292
Mailing Address - Country:US
Mailing Address - Phone:262-654-6770
Mailing Address - Fax:262-654-6727
Practice Address - Street 1:5021 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53144-4292
Practice Address - Country:US
Practice Address - Phone:262-654-6770
Practice Address - Fax:262-654-6727
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI7210-15204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program