Provider Demographics
NPI:1497798136
Name:GIBBS, THOMAS W (DDS)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:W
Last Name:GIBBS
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 1:857 AUTO MALL RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47440-5447
Mailing Address - Country:US
Mailing Address - Phone:812-332-2204
Mailing Address - Fax:812-332-9095
Practice Address - Street 1:857 AUTO MALL RD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47440-5447
Practice Address - Country:US
Practice Address - Phone:812-332-2204
Practice Address - Fax:812-332-9095
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12006707A1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000325306OtherANTHEM BCBS
000000325306OtherANTHEM BCBS
IN206630Medicare ID - Type Unspecified