Provider Demographics
NPI:1285772350
Name:GIBSON, CHARLES GARY (DDS)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:GARY
Last Name:GIBSON
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 1:2068 BRIDGEPORT AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06460-4634
Mailing Address - Country:US
Mailing Address - Phone:203-874-7444
Mailing Address - Fax:
Practice Address - Street 1:2068 BRIDGEPORT AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-4634
Practice Address - Country:US
Practice Address - Phone:203-874-7444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005884122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist