Provider Demographics
NPI:1114090131
Name:GIBSON, MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:GIBSON
Suffix:
Gender:M
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:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:DORCHESTER
Mailing Address - State:WI
Mailing Address - Zip Code:54425-0236
Mailing Address - Country:US
Mailing Address - Phone:715-654-5911
Mailing Address - Fax:715-654-5937
Practice Address - Street 1:424 E CENTER AVENUE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:WI
Practice Address - Zip Code:54425-0236
Practice Address - Country:US
Practice Address - Phone:715-654-5911
Practice Address - Fax:715-654-5937
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI28551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33434800Medicaid
WI3432OtherFAMILY HEALTH CENTER