1255385696 NPI number — DR. ROMAN M CIBIRKA DDS

Table of content: DR. ROMAN M CIBIRKA DDS (NPI 1255385696)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255385696 NPI number — DR. ROMAN M CIBIRKA DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CIBIRKA
Provider First Name:
ROMAN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

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:
1255385696
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/13/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
541 BROOKWOOD DR W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAWSONVILLE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30534-7563
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
706-564-8174
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
541 BROOKWOOD DR W
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAWSONVILLE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30534-7563
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
706-564-8174
Provider Business Practice Location Address Fax Number:
706-721-6778
Provider Enumeration Date:
05/20/2006

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: 1223P0700X , with the licence number:  DN011807 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000812534A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: ZG1807 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com