Provider Demographics
NPI:1174679328
Name:GIBBONS, WALTER SMITH (DDS)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:SMITH
Last Name:GIBBONS
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 1:113 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-4104
Mailing Address - Country:US
Mailing Address - Phone:757-595-0983
Mailing Address - Fax:
Practice Address - Street 1:113 MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-4104
Practice Address - Country:US
Practice Address - Phone:757-595-0983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA53461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice