Provider Demographics
NPI:1043388234
Name:GIBSON, WILLIAM BURLIN (DMD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:BURLIN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10447 DRYHILL ROAD
Mailing Address - Street 2:
Mailing Address - City:CONFLUENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41749
Mailing Address - Country:US
Mailing Address - Phone:606-672-2075
Mailing Address - Fax:606-487-1849
Practice Address - Street 1:200 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 2-O
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9466
Practice Address - Country:US
Practice Address - Phone:606-487-0088
Practice Address - Fax:606-487-1849
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY7055204E00000X, 1223S0112X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60070554Medicaid
VA238396OtherBLUE CROSS BLUE SHIELD VA
KY000000236923OtherBLUE CROSS BLUE SHILED KY
343574OtherUNITED CONCORDIA INS
KY64342546Medicaid
KY1826801Medicare ID - Type Unspecified
KY60070554Medicaid