Provider Demographics
NPI:1033287115
Name:SIBLEY, LONNIE M JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:LONNIE
Middle Name:M
Last Name:SIBLEY
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1285 CENTAUR VILLAGE DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-1214
Mailing Address - Country:US
Mailing Address - Phone:720-287-2614
Mailing Address - Fax:303-200-7375
Practice Address - Street 1:4155 DARLEY AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80305-6536
Practice Address - Country:US
Practice Address - Phone:303-499-7072
Practice Address - Fax:303-200-7375
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1042331223S0112X
LA27591223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02042331Medicaid