Provider Demographics
NPI:1417911496
Name:GIBSON, JAN MARIE
Entity Type:Individual
Prefix:MS
First Name:JAN
Middle Name:MARIE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 SHERIDAN RD
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79906-3803
Mailing Address - Country:US
Mailing Address - Phone:253-283-9106
Mailing Address - Fax:
Practice Address - Street 1:BLDG 128 CHAFFEE RD, US ARMY DENTAL ACTIVITY
Practice Address - Street 2:ATTN: DENTAC HEADQUEARTERS
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79916
Practice Address - Country:US
Practice Address - Phone:915-742-6001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6445124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist