Provider Demographics
NPI:1386652568
Name:GIBSON, T. MICHAEL (DDS)
Entity Type:Individual
Prefix:
First Name:T.
Middle Name:MICHAEL
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 1:3 GROGANS PARK DR
Mailing Address - Street 2:STE: 100
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77380-2192
Mailing Address - Country:US
Mailing Address - Phone:281-364-9880
Mailing Address - Fax:281-419-2370
Practice Address - Street 1:3 GROGANS PARK DR
Practice Address - Street 2:STE: 100
Practice Address - City:THE WOODLANDS
Practice Address - State:TX
Practice Address - Zip Code:77380-2192
Practice Address - Country:US
Practice Address - Phone:281-364-9880
Practice Address - Fax:281-419-2370
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX147581223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX14758OtherSTATE LICENSE NUMBER