Provider Demographics
NPI:1710182985
Name:GIBSON, KIMBERLEY ANN (RDH)
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:ANN
Last Name:GIBSON
Suffix:
Gender:F
Credentials:RDH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16314 96TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98375-9677
Mailing Address - Country:US
Mailing Address - Phone:253-848-5698
Mailing Address - Fax:
Practice Address - Street 1:104 39TH AVE SW STE E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-5960
Practice Address - Country:US
Practice Address - Phone:253-841-1386
Practice Address - Fax:253-841-5995
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADH00004162124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist