Provider Demographics
NPI:1982213971
Name:GIBSON, AMBER SIMMONS (DDS)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:SIMMONS
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 TOLLIE MARKHAM RD
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:TN
Mailing Address - Zip Code:38330-4225
Mailing Address - Country:US
Mailing Address - Phone:731-414-5632
Mailing Address - Fax:
Practice Address - Street 1:20 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HOHENWALD
Practice Address - State:TN
Practice Address - Zip Code:38462-1420
Practice Address - Country:US
Practice Address - Phone:931-796-7577
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN113781223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN11378OtherDDS LICENSE