Provider Demographics
NPI:1790070712
Name:GIBSON, NICOLE LEE (RDH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
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 1:1537 W SAN BERNARDINO RD
Mailing Address - Street 2:APT. #C
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-1016
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1406 N AZUSA AVE
Practice Address - Street 2:UNIT #C
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91722-1257
Practice Address - Country:US
Practice Address - Phone:626-858-9940
Practice Address - Fax:626-858-9366
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23400124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist