Provider Demographics
NPI:1376895904
Name:SIBRAVA, LAURA JUDSON (DMD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JUDSON
Last Name:SIBRAVA
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21479 N 78TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-3336
Mailing Address - Country:US
Mailing Address - Phone:847-630-4256
Mailing Address - Fax:
Practice Address - Street 1:21809 N SCOTTSDALE RD
Practice Address - Street 2:SUITE C-105
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-7440
Practice Address - Country:US
Practice Address - Phone:480-563-0000
Practice Address - Fax:480-563-4445
Is Sole Proprietor?:No
Enumeration Date:2012-10-05
Last Update Date:2017-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8534122300000X
NMDD3813122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM25501585Medicaid