Provider Demographics
NPI:1114671997
Name:MUSSIE SIBHATU DDS, A DENTAL CORPORATION
Entity Type:Organization
Organization Name:MUSSIE SIBHATU DDS, A DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUSSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIBHATU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:510-520-1533
Mailing Address - Street 1:3147 TELEGRAPH AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3206
Mailing Address - Country:US
Mailing Address - Phone:510-420-1717
Mailing Address - Fax:
Practice Address - Street 1:3630 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94619-1328
Practice Address - Country:US
Practice Address - Phone:510-530-3317
Practice Address - Fax:510-530-3370
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MUSSIE SIBHATU DDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD1288907OtherDENTAL INSURANCE