Provider Demographics
NPI:1538137237
Name:GIBBONS, MICHELLE (RDH)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301A E PRICE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:MO
Mailing Address - Zip Code:64485-1739
Mailing Address - Country:US
Mailing Address - Phone:816-324-5644
Mailing Address - Fax:816-324-6307
Practice Address - Street 1:301A E PRICE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:MO
Practice Address - Zip Code:64485-1739
Practice Address - Country:US
Practice Address - Phone:816-324-5644
Practice Address - Fax:816-324-6307
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004014076124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OTH000Medicare UPIN