Provider Demographics
NPI:1629462429
Name:GIBSON, CHRISTOPHER WALTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:WALTER
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 1:1510 LEXINGTON AVE APT 9H
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-7161
Mailing Address - Country:US
Mailing Address - Phone:978-758-8728
Mailing Address - Fax:
Practice Address - Street 1:3630 HILL BLVD STE 101
Practice Address - Street 2:
Practice Address - City:JEFFERSON VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10535-1503
Practice Address - Country:US
Practice Address - Phone:914-245-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT118151223P0221X
NY059580-11223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty