Provider Demographics
NPI:1972668572
Name:GIBSON, GRADY A (DMD)
Entity type:Individual
Prefix:DR
First Name:GRADY
Middle Name:A
Last Name:GIBSON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 OVERTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2064
Mailing Address - Country:US
Mailing Address - Phone:859-581-1400
Mailing Address - Fax:859-581-0126
Practice Address - Street 1:701 OVERTON ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-2064
Practice Address - Country:US
Practice Address - Phone:859-581-1400
Practice Address - Fax:859-581-0126
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50871223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice