Provider Demographics
NPI:1174807705
Name:TIBBS-HNIZDO, KYLEA MARIE (DMD)
Entity type:Individual
Prefix:MRS
First Name:KYLEA
Middle Name:MARIE
Last Name:TIBBS-HNIZDO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62675-1621
Mailing Address - Country:US
Mailing Address - Phone:217-415-2426
Mailing Address - Fax:
Practice Address - Street 1:2239 E COOK ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62703-1944
Practice Address - Country:US
Practice Address - Phone:217-788-2300
Practice Address - Fax:217-788-2342
Is Sole Proprietor?:No
Enumeration Date:2011-09-30
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019028844122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist