Provider Demographics
NPI:1255505277
Name:GIBBONS, THOMAS J (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:J
Last Name:GIBBONS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:TOM
Other - Middle Name:J
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:701 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WESTBY
Mailing Address - State:WI
Mailing Address - Zip Code:54667
Mailing Address - Country:US
Mailing Address - Phone:608-634-3978
Mailing Address - Fax:608-634-6205
Practice Address - Street 1:701 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WESTBY
Practice Address - State:WI
Practice Address - Zip Code:54667
Practice Address - Country:US
Practice Address - Phone:608-634-3978
Practice Address - Fax:608-634-6205
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33455700Medicaid