Provider Demographics
NPI:1144381427
Name:GIBSON, GLENN EDWARD (DDS)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:EDWARD
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 1:885 CANARIOS CT
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7877
Mailing Address - Country:US
Mailing Address - Phone:619-216-9481
Mailing Address - Fax:619-216-9461
Practice Address - Street 1:885 CANARIOS CT
Practice Address - Street 2:SUITE 204
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-7877
Practice Address - Country:US
Practice Address - Phone:619-216-9481
Practice Address - Fax:619-216-9461
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA330911223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice