Provider Demographics
NPI:1134289812
Name:GIBBS, LORI ANN AMELIA
Entity Type:Individual
Prefix:MRS
First Name:LORI ANN
Middle Name:AMELIA
Last Name:GIBBS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 KNOLLWOOD LANE
Mailing Address - Street 2:
Mailing Address - City:NEW FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06812
Mailing Address - Country:US
Mailing Address - Phone:203-746-3772
Mailing Address - Fax:
Practice Address - Street 1:3 SCHOOL STREET
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:CT
Practice Address - Zip Code:06801
Practice Address - Country:US
Practice Address - Phone:203-744-1646
Practice Address - Fax:203-798-6801
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002658124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist