Provider Demographics
NPI:1619097706
Name:GIBSON, CHIANN FAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHIANN
Middle Name:FAN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 W GALENA BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3255
Mailing Address - Country:US
Mailing Address - Phone:630-544-1419
Mailing Address - Fax:630-566-0490
Practice Address - Street 1:55 S MAIN ST
Practice Address - Street 2:SUITE 290
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60540-5372
Practice Address - Country:US
Practice Address - Phone:630-357-3333
Practice Address - Fax:630-357-3334
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2010-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019024641122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist