Provider Demographics
NPI:1669503751
Name:GIBSON, KENNETH P (DDS)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:P
Last Name:GIBSON
Suffix:
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 1:1871 NE 163RD ST
Mailing Address - Street 2:
Mailing Address - City:NORTH MIAMI BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33162-4805
Mailing Address - Country:US
Mailing Address - Phone:305-354-2213
Mailing Address - Fax:305-945-9277
Practice Address - Street 1:1871 NE 163RD ST
Practice Address - Street 2:
Practice Address - City:NORTH MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33162-4805
Practice Address - Country:US
Practice Address - Phone:305-354-2213
Practice Address - Fax:305-945-9277
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 00114521223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice