Provider Demographics
NPI:1528257896
Name:TOKATLY, TIBA MOWAFAK (DDS)
Entity type:Individual
Prefix:DR
First Name:TIBA
Middle Name:MOWAFAK
Last Name:TOKATLY
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26400 W 12 MILE RD
Mailing Address - Street 2:SUITE#160
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48034-1700
Mailing Address - Country:US
Mailing Address - Phone:248-356-8567
Mailing Address - Fax:248-356-3442
Practice Address - Street 1:26400 W 12 MILE RD
Practice Address - Street 2:SUITE#160
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1700
Practice Address - Country:US
Practice Address - Phone:248-356-8567
Practice Address - Fax:248-356-3442
Is Sole Proprietor?:No
Enumeration Date:2007-10-23
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2901019710122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist