Provider Demographics
NPI:1578998381
Name:GIBSON FAMILY DENTISTRY, PLLC
Entity Type:Organization
Organization Name:GIBSON FAMILY DENTISTRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BILL
Authorized Official - Middle Name:J
Authorized Official - Last Name:GIBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:304-965-1200
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:ELKVIEW
Mailing Address - State:WV
Mailing Address - Zip Code:25071-0009
Mailing Address - Country:US
Mailing Address - Phone:304-965-1200
Mailing Address - Fax:304-965-6158
Practice Address - Street 1:5089 ELK RIVER ROAD N.
Practice Address - Street 2:
Practice Address - City:ELKVIEW
Practice Address - State:WV
Practice Address - Zip Code:25071
Practice Address - Country:US
Practice Address - Phone:304-965-1200
Practice Address - Fax:304-965-6158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-11
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0135148000Medicaid