Provider Demographics
NPI:1083991053
Name:TIBBETTS, DANIEL PATRICK (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:PATRICK
Last Name:TIBBETTS
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 1:611 WOODCREST AVE
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-1919
Mailing Address - Country:US
Mailing Address - Phone:302-545-9444
Mailing Address - Fax:
Practice Address - Street 1:111 S INDEPENDENCE MALL E
Practice Address - Street 2:SUITE 610
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-2515
Practice Address - Country:US
Practice Address - Phone:215-238-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS039118122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist