Provider Demographics
NPI:1528595501
Name:GIBSON, SCOTT ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:ROBERT
Last Name:GIBSON
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 1:2945 MYSTIC DR
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-8910
Mailing Address - Country:US
Mailing Address - Phone:435-313-1681
Mailing Address - Fax:
Practice Address - Street 1:1515 E US HIGHWAY 223
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-4456
Practice Address - Country:US
Practice Address - Phone:517-215-7104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-22
Last Update Date:2017-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010221781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice