Provider Demographics
NPI:1255385696
Name:CIBIRKA, ROMAN M (DDS)
Entity type:Individual
Prefix:DR
First Name:ROMAN
Middle Name:M
Last Name:CIBIRKA
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 1:541 BROOKWOOD DR W
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-7563
Mailing Address - Country:US
Mailing Address - Phone:706-564-8174
Mailing Address - Fax:
Practice Address - Street 1:541 BROOKWOOD DR W
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-7563
Practice Address - Country:US
Practice Address - Phone:706-564-8174
Practice Address - Fax:706-721-6778
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0118071223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000812534AMedicaid
SCZG1807Medicaid