Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DE60660680 | WA |
NPI | 1023429156 |
---|---|
Provider Name | John Gibbons |
First Address | Tacoma, WA 98405-4254 |
Second Address | Tacoma, WA 98405-4254 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/05/2014 |
Last Update Date | 24/06/2020 |