Provider Demographics
NPI:1679217343
Name:GAMBLIN, BENTLEY GAIGE
Entity Type:Individual
Prefix:
First Name:BENTLEY
Middle Name:GAIGE
Last Name:GAMBLIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 17TH AVE APT 129
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-6148
Mailing Address - Country:US
Mailing Address - Phone:480-307-5262
Mailing Address - Fax:
Practice Address - Street 1:825 17TH AVE APT 129
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6148
Practice Address - Country:US
Practice Address - Phone:480-307-5262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker