Provider Demographics
NPI:1710116264
Name:GIBSON, ALISSA LAUREN (DDS)
Entity Type:Individual
Prefix:
First Name:ALISSA
Middle Name:LAUREN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:LAUREN
Other - Last Name:MAUL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:926 KATHERINE AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-3625
Mailing Address - Country:US
Mailing Address - Phone:419-281-7771
Mailing Address - Fax:
Practice Address - Street 1:926 KATHERINE AVE STE 1
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-3625
Practice Address - Country:US
Practice Address - Phone:419-281-7771
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-06
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30-023041122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist