Provider Demographics
NPI:1831643691
Name:GIBSON, TRAVIS LAWRENCE (DMD)
Entity Type:Individual
Prefix:DR
First Name:TRAVIS
Middle Name:LAWRENCE
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 E 20TH ST
Mailing Address - Street 2:UNIT 11A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-7602
Mailing Address - Country:US
Mailing Address - Phone:917-519-3413
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:NYU LANGONE MEDICAL CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-10
Last Update Date:2016-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058591-1390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program