Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223P0221X | Pediatric Dentist | DE05994 | WA |
NPI | 1023233046 |
---|---|
Provider Name | John L Gibbons |
First Address | Silverdale, WA 98383-7801 |
Second Address | Silverdale, WA 98383-7801 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/04/2007 |
Last Update Date | 08/07/2007 |