Provider Demographics
NPI:1184712952
Name:CANDICE L. GIBBONS, D.D.S., P.C.
Entity type:Organization
Organization Name:CANDICE L. GIBBONS, D.D.S., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CANDICE
Authorized Official - Middle Name:LEIGH
Authorized Official - Last Name:GIBBONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:815-485-2536
Mailing Address - Street 1:2449 E JOLIET HWY
Mailing Address - Street 2:
Mailing Address - City:NEW LENOX
Mailing Address - State:IL
Mailing Address - Zip Code:60451-2592
Mailing Address - Country:US
Mailing Address - Phone:815-485-2536
Mailing Address - Fax:815-485-2645
Practice Address - Street 1:2449 E JOLIET HWY
Practice Address - Street 2:
Practice Address - City:NEW LENOX
Practice Address - State:IL
Practice Address - Zip Code:60451-2592
Practice Address - Country:US
Practice Address - Phone:815-485-2536
Practice Address - Fax:815-485-2645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019.0244591223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty