Provider Demographics
NPI:1346933751
Name:HIBBERT, BRAXTON
Entity Type:Individual
Prefix:
First Name:BRAXTON
Middle Name:
Last Name:HIBBERT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6611 E MAYO BLVD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85054-4507
Mailing Address - Country:US
Mailing Address - Phone:928-607-8386
Mailing Address - Fax:
Practice Address - Street 1:35004 N NORTH VALLEY PKWY STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85086-3255
Practice Address - Country:US
Practice Address - Phone:623-879-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-31
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD0118051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice