Provider Demographics
NPI:1881255859
Name:GIBBS, TREVOR
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:
Last Name:GIBBS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2765 LEXINGTON AVE, UNIT A
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-2005
Mailing Address - Country:US
Mailing Address - Phone:507-317-8123
Mailing Address - Fax:
Practice Address - Street 1:1 VETERANS DR
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55417-2309
Practice Address - Country:US
Practice Address - Phone:507-317-8123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND142661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice