Provider Demographics
NPI:1215777438
Name:GIBSON, MAKENNA BRIANNE (DMD)
Entity type:Individual
Prefix:
First Name:MAKENNA
Middle Name:BRIANNE
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MAKENNA
Other - Middle Name:BRIANNE
Other - Last Name:THIBODEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10914 NAGEL CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40241-4855
Mailing Address - Country:US
Mailing Address - Phone:606-215-9255
Mailing Address - Fax:
Practice Address - Street 1:10914 NAGEL CT
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40241-4855
Practice Address - Country:US
Practice Address - Phone:606-215-9255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111201223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics