Provider Demographics
NPI:1932214475
Name:TIBURON FAMILY DENTAL PC
Entity Type:Organization
Organization Name:TIBURON FAMILY DENTAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:H
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:402-932-9413
Mailing Address - Street 1:16919 AUDREY ST
Mailing Address - Street 2:SUITE 40
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136
Mailing Address - Country:US
Mailing Address - Phone:402-932-9413
Mailing Address - Fax:402-505-9704
Practice Address - Street 1:16919 AUDREY ST
Practice Address - Street 2:SUITE 40
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68136
Practice Address - Country:US
Practice Address - Phone:402-932-9413
Practice Address - Fax:402-505-9704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE6576122300000X
UT3417859922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty