Provider Demographics
NPI:1760401830
Name:GIBBONS, DOUGLAS BRIAN III (DDS)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:BRIAN
Last Name:GIBBONS
Suffix:III
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1101 MEDICAL ARTS AVE NE
Mailing Address - Street 2:SANDIA MEDICAL PARK BLDG. # 1
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87102-2706
Mailing Address - Country:US
Mailing Address - Phone:505-842-0808
Mailing Address - Fax:505-842-1165
Practice Address - Street 1:1101 MEDICAL ARTS AVE NE
Practice Address - Street 2:SANDIA MEDICAL PARK BLDG. # 1
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2706
Practice Address - Country:US
Practice Address - Phone:505-842-0808
Practice Address - Fax:505-842-1165
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD14831223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice