Provider Demographics
NPI:1700152394
Name:GIBSON, TRACY A (DMD)
Entity Type:Individual
Prefix:MS
First Name:TRACY
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 WOOD LOT TRAIL RD
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-6466
Mailing Address - Country:US
Mailing Address - Phone:410-224-4014
Mailing Address - Fax:
Practice Address - Street 1:975 EASTON RD
Practice Address - Street 2:SUITE 101
Practice Address - City:WARRINGTON
Practice Address - State:PA
Practice Address - Zip Code:18976-1858
Practice Address - Country:US
Practice Address - Phone:866-916-6447
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD13659122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist