Provider Demographics
NPI:1497979645
Name:WILLIAM E GIPSON DDS PC
Entity Type:Organization
Organization Name:WILLIAM E GIPSON DDS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OF CORPORATION
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:GIPSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:708-352-1495
Mailing Address - Street 1:6 SO SIXTH AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2401
Mailing Address - Country:US
Mailing Address - Phone:708-352-1495
Mailing Address - Fax:708-352-1524
Practice Address - Street 1:6 SO SIXTH AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2401
Practice Address - Country:US
Practice Address - Phone:708-352-1495
Practice Address - Fax:708-352-1524
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2012-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190145661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTAX ID