Provider Demographics
NPI:1912202169
Name:GIMBRONE, CARL JOHN JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:JOHN
Last Name:GIMBRONE
Suffix:JR
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 1:650 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2060
Mailing Address - Country:US
Mailing Address - Phone:508-532-7318
Mailing Address - Fax:508-853-8593
Practice Address - Street 1:19 TACOMA ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605-3516
Practice Address - Country:US
Practice Address - Phone:508-854-3255
Practice Address - Fax:508-853-8593
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MADN1855572122300000X
CT10443122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist