Provider Demographics
NPI:1366834491
Name:PHILIP L. GIBSON, DMD, PA
Entity Type:Organization
Organization Name:PHILIP L. GIBSON, DMD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:850-932-2266
Mailing Address - Street 1:13 CENTER ST
Mailing Address - Street 2:
Mailing Address - City:GULF BREEZE
Mailing Address - State:FL
Mailing Address - Zip Code:32561-4370
Mailing Address - Country:US
Mailing Address - Phone:850-932-2266
Mailing Address - Fax:850-934-1242
Practice Address - Street 1:13 CENTER ST
Practice Address - Street 2:
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-4370
Practice Address - Country:US
Practice Address - Phone:850-932-2266
Practice Address - Fax:850-934-1242
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-26
Last Update Date:2016-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16723122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty