Provider Demographics
NPI:1255882171
Name:KIBLER, THERESA J (RDH)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:J
Last Name:KIBLER
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 CALLE PORTAL STE 100
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2900
Mailing Address - Country:US
Mailing Address - Phone:520-459-3012
Mailing Address - Fax:
Practice Address - Street 1:4525 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2232
Practice Address - Country:US
Practice Address - Phone:520-459-3011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-14
Last Update Date:2016-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZH04638124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist