1861794430 NPI number — KACI L. TIBBETTS DDS

Table of content: KACI L. TIBBETTS DDS (NPI 1861794430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861794430 NPI number — KACI L. TIBBETTS DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TIBBETTS
Provider First Name:
KACI
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861794430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7703 FLOYD CURL DRIVE UT HEALTH SCIENCE CENTER AT SAN A
Provider Second Line Business Mailing Address:
MSC 7914, DEPT OF COMPREHENSIVE DENTISTRY
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3900
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-567-3456
Provider Business Mailing Address Fax Number:
210-567-3443

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3223 THOUSAND OAKS DR STE 102
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78247-3573
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-496-5422
Provider Business Practice Location Address Fax Number:
210-490-2388
Provider Enumeration Date:
12/02/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  26455 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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