MEDICARE: ROBERT LAWRENCE GIBSON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	1451829922	UT

General Provider Information

NPI Number	:	1083788350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT LAWRENCE GIBSON DDS

Provider Business Mailing Address
First Line	:	2303 N CORAL CANYON BLVD #202
Second Line	:
City	:	WASHINGTON
State	:	UT
Zip	:	84780
Country	:	US
Telephone Number	:	435-652-4284
Fax Number	:	435-652-4309

Provider Business Practice Location Address
First Line	:	2303 N CORAL CANYON BLVD #202
Second Line	:
City	:	WASHINGTON
State	:	UT
Zip	:	84780
Country	:	US
Telephone Number	:	435-652-4284
Fax Number	:	435-652-4309

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2006
Last Update Date	:	07/08/2007

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