Provider Demographics
NPI:1376755942
Name:SIBHATU, MUSSIE (DDS)
Entity Type:Individual
Prefix:
First Name:MUSSIE
Middle Name:
Last Name:SIBHATU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3630 MACARTHUR BLVD
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94619-1328
Mailing Address - Country:US
Mailing Address - Phone:510-530-3317
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
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019205122300000X
CA59276122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty