Provider Demographics
NPI:1750616520
Name:TYBERG, MICAH JOHN (DDS)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:JOHN
Last Name:TYBERG
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 1:1055 CLERMONT ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-3808
Mailing Address - Country:US
Mailing Address - Phone:303-393-2823
Mailing Address - Fax:
Practice Address - Street 1:1055 CLERMONT ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80220-3808
Practice Address - Country:US
Practice Address - Phone:303-393-2823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-12
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program