Provider Demographics
NPI:1487662375
Name:RUSSELL J TIBBETTS DDS PA
Entity type:Organization
Organization Name:RUSSELL J TIBBETTS DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:J
Authorized Official - Last Name:TIBBETTS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-479-5959
Mailing Address - Street 1:3516 SILVERSIDE ROAD
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 ROAD
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE894122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty