Provider Demographics
NPI:1134644149
Name:TIBBITTS MENIFEE DENTAL GROUP
Entity Type:Organization
Organization Name:TIBBITTS MENIFEE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:VALERIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-677-5113
Mailing Address - Street 1:27701 SCOTT RD STE 107
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-9434
Mailing Address - Country:US
Mailing Address - Phone:951-301-6100
Mailing Address - Fax:951-301-3669
Practice Address - Street 1:27701 SCOTT RD STE 107
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92584-9434
Practice Address - Country:US
Practice Address - Phone:951-301-6100
Practice Address - Fax:951-301-3669
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53656261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental