Provider Demographics
NPI:1770196024
Name:BIBERA, KEVIN TAN (DDS)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:TAN
Last Name:BIBERA
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 1:1854 CLAIRE CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94519-2359
Mailing Address - Country:US
Mailing Address - Phone:424-325-9270
Mailing Address - Fax:
Practice Address - Street 1:875 UNION AVENUE SUITE C211
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38163-8781
Practice Address - Country:US
Practice Address - Phone:901-448-7180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-26
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1050251223G0001X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice