Provider Demographics
NPI:1639365695
Name:GIBSON, KEITH EDWARD JR (DDS)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:EDWARD
Last Name:GIBSON
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 NW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73107-6037
Mailing Address - Country:US
Mailing Address - Phone:405-942-6222
Mailing Address - Fax:405-946-3112
Practice Address - Street 1:3906 NW 10TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73107-6037
Practice Address - Country:US
Practice Address - Phone:405-942-6222
Practice Address - Fax:405-946-3112
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-23
Last Update Date:2007-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4690122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist