Provider Demographics
NPI:1154586170
Name:O, GIBSON (DDS)
Entity type:Individual
Prefix:DR
First Name:GIBSON
Middle Name:
Last Name:O
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:2150 HIGHWAY 54 S
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-7330
Practice Address - Country:US
Practice Address - Phone:575-443-8133
Practice Address - Fax:575-443-8055
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-21
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0024099122300000X
NY053883122300000X
NMDD4194122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist