Provider Demographics
NPI:1790471571
Name:GIBBONS, JALEN LAWRENCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:JALEN
Middle Name:LAWRENCE
Last Name:GIBBONS
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 1:5800 N INTERSTATE 35 STE 205
Mailing Address - Street 2:
Mailing Address - City:DENTON
Mailing Address - State:TX
Mailing Address - Zip Code:76207-1438
Mailing Address - Country:US
Mailing Address - Phone:940-220-7833
Mailing Address - Fax:
Practice Address - Street 1:4122 S STAPLES ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-2109
Practice Address - Country:US
Practice Address - Phone:361-949-5215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX394801223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program