Provider Demographics
NPI:1497098206
Name:GIBSON, PAMELA A (DMD)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:
Other - Last Name:KARKUT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:10 JOHN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-1437
Mailing Address - Country:US
Mailing Address - Phone:203-255-5142
Mailing Address - Fax:203-259-5954
Practice Address - Street 1:10 JOHN ST
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-1437
Practice Address - Country:US
Practice Address - Phone:203-255-5142
Practice Address - Fax:203-259-5954
Is Sole Proprietor?:No
Enumeration Date:2013-03-29
Last Update Date:2020-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT11244122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program