Provider Demographics
NPI:1396825170
Name:GIBBS, ROGER DALE (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:DALE
Last Name:GIBBS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 E 10TH ST
Mailing Address - Street 2:STE D
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-4776
Mailing Address - Country:US
Mailing Address - Phone:256-237-3529
Mailing Address - Fax:256-237-3535
Practice Address - Street 1:711 E 10TH ST
Practice Address - Street 2:STE D
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-4776
Practice Address - Country:US
Practice Address - Phone:256-237-3529
Practice Address - Fax:256-237-3535
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL31001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice