Provider Demographics
NPI:1831670793
Name:GIBBONS, SPENCER (DDS)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:
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 1:2155 KETTNER BLVD UNIT 613
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-1768
Mailing Address - Country:US
Mailing Address - Phone:505-270-5792
Mailing Address - Fax:
Practice Address - Street 1:2155 KETTNER BLVD UNIT 613
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-1768
Practice Address - Country:US
Practice Address - Phone:505-270-5792
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS102802122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist