Provider Demographics
NPI:1275721086
Name:WILLIAM B GIBSON, DMD, PSC
Entity Type:Organization
Organization Name:WILLIAM B GIBSON, DMD, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:B
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:606-487-0088
Mailing Address - Street 1:200 MEDICAL CENTER DR
Mailing Address - Street 2:STE 2-O
Mailing Address - City:HAZARD
Mailing Address - State:KY
Mailing Address - Zip Code:41701-9466
Mailing Address - Country:US
Mailing Address - Phone:606-487-0088
Mailing Address - Fax:606-487-1849
Practice Address - Street 1:200 MEDICAL CENTER DR
Practice Address - Street 2:STE 2-O
Practice Address - City:HAZARD
Practice Address - State:KY
Practice Address - Zip Code:41701-9466
Practice Address - Country:US
Practice Address - Phone:606-487-0088
Practice Address - Fax:606-487-1849
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY70551223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64342546Medicaid