Provider Demographics
NPI:1629276837
Name:GIBSON, DYLAN JOHN (DMD)
Entity Type:Individual
Prefix:
First Name:DYLAN
Middle Name:JOHN
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1280 S UTE AVE
Mailing Address - Street 2:SUITE #23
Mailing Address - City:ASPEN
Mailing Address - State:CO
Mailing Address - Zip Code:81611-2126
Mailing Address - Country:US
Mailing Address - Phone:970-925-6565
Mailing Address - Fax:970-920-6566
Practice Address - Street 1:1280 S UTE AVE
Practice Address - Street 2:SUITE #23
Practice Address - City:ASPEN
Practice Address - State:CO
Practice Address - Zip Code:81611-2126
Practice Address - Country:US
Practice Address - Phone:970-925-6565
Practice Address - Fax:970-920-6566
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO55471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice