Provider Demographics
NPI:1154431583
Name:MCKIBBEN, RICHARD DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:DALE
Last Name:MCKIBBEN
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 S HIGHLAND AVE
Mailing Address - Street 2:STE 3
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33756
Mailing Address - Country:US
Mailing Address - Phone:727-446-7332
Mailing Address - Fax:727-443-4328
Practice Address - Street 1:1201 S HIGHLAND AVE
Practice Address - Street 2:STE 3
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756
Practice Address - Country:US
Practice Address - Phone:727-446-7332
Practice Address - Fax:727-443-4328
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLFL4878D122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist