Provider Demographics
NPI:1669501599
Name:TIBURCIO, AMOR G (DMD)
Entity Type:Individual
Prefix:DR
First Name:AMOR
Middle Name:G
Last Name:TIBURCIO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2368 COBALT LN
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-1792
Mailing Address - Country:US
Mailing Address - Phone:215-350-0649
Mailing Address - Fax:
Practice Address - Street 1:1140 2ND ST STE D
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2239
Practice Address - Country:US
Practice Address - Phone:925-240-7024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0365481223G0001X
CA567271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice