Provider Demographics
NPI:1689676025
Name:GIBSON, MELISSA PAIGE (DDS, MSD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:PAIGE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DDS, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 W JUBAL EARLY DR STE 101
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22601-6517
Mailing Address - Country:US
Mailing Address - Phone:540-628-8533
Mailing Address - Fax:540-750-4042
Practice Address - Street 1:5465 NE 1ST LN
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-3418
Practice Address - Country:US
Practice Address - Phone:917-224-4968
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2018-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401411741122300000X, 1223P0221X
NY050886-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice