Provider Demographics
NPI:1255402616
Name:GIBSON, YENDIS L (DDS)
Entity type:Individual
Prefix:DR
First Name:YENDIS
Middle Name:L
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:YENDIS
Other - Middle Name:
Other - Last Name:GIBSON-KING
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:315 WOODLAWN AVE
Mailing Address - Street 2:
Mailing Address - City:GLENCOE
Mailing Address - State:IL
Mailing Address - Zip Code:60022-2122
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3419 DEMPSTER ST
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-2441
Practice Address - Country:US
Practice Address - Phone:847-568-1337
Practice Address - Fax:847-568-1437
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190171021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL019017102OtherSTATE LICENSE
IL019017102OtherSTATE LICENSE