Provider Demographics
NPI:1073998944
Name:GIBSON, RISE A (RDH)
Entity Type:Individual
Prefix:
First Name:RISE
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36320 COUNTY HIGHWAY 122
Mailing Address - Street 2:
Mailing Address - City:BARNESVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43713
Mailing Address - Country:US
Mailing Address - Phone:740-425-3390
Mailing Address - Fax:
Practice Address - Street 1:342 MUSKINGUM DRIVE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:OH
Practice Address - Zip Code:45750
Practice Address - Country:US
Practice Address - Phone:740-374-2782
Practice Address - Fax:740-376-7074
Is Sole Proprietor?:No
Enumeration Date:2015-07-21
Last Update Date:2015-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH31-003462124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist