Provider Demographics
NPI:1780690404
Name:GIBBS, WYLAND WILSON (DDS)
Entity Type:Individual
Prefix:
First Name:WYLAND
Middle Name:WILSON
Last Name:GIBBS
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 1:2139 WILDFIELD DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6321
Mailing Address - Country:US
Mailing Address - Phone:616-361-8506
Mailing Address - Fax:
Practice Address - Street 1:2139 WILDFIELD DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6321
Practice Address - Country:US
Practice Address - Phone:616-361-8506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010076481223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics