Provider Demographics
NPI:1366715419
Name:TIBBETTS, RUSSELL J (DDS)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:J
Last Name:TIBBETTS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3516 SILVERSIDE RD
Mailing Address - Street 2:#17 THE COMMONS
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-4932
Mailing Address - Country:US
Mailing Address - Phone:302-479-5959
Mailing Address - Fax:302-479-5956
Practice Address - Street 1:3516 SILVERSIDE RD
Practice Address - Street 2:#17 THE COMMONS
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-4932
Practice Address - Country:US
Practice Address - Phone:302-479-5959
Practice Address - Fax:302-479-5956
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-21
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE8941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice