Provider Demographics
NPI:1689381493
Name:GIBSON, BRANDON (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:
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 1:13020 PACIFIC PROMENADE UNIT 315
Mailing Address - Street 2:
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-4019
Mailing Address - Country:US
Mailing Address - Phone:201-988-4541
Mailing Address - Fax:
Practice Address - Street 1:13020 PACIFIC PROMENADE UNIT 315
Practice Address - Street 2:
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-4019
Practice Address - Country:US
Practice Address - Phone:201-988-4541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1083361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice