Provider Demographics
NPI:1558786889
Name:GIBILISCO, KRISTEN MARIE (DMD)
Entity Type:Individual
Prefix:DR
First Name:KRISTEN
Middle Name:MARIE
Last Name:GIBILISCO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:DR
Other - First Name:KRISTEN
Other - Middle Name:MARIE
Other - Last Name:BONKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DMD
Mailing Address - Street 1:369 HEINEBERG DR
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:VT
Mailing Address - Zip Code:05446-6774
Mailing Address - Country:US
Mailing Address - Phone:802-658-4873
Mailing Address - Fax:
Practice Address - Street 1:369 HEINEBERG DR
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:VT
Practice Address - Zip Code:05446-6774
Practice Address - Country:US
Practice Address - Phone:802-658-4873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-24
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1856545122300000X
GADN014807122300000X
VT016.0134062122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist