MEDICARE: DR. RICHARD WILLIAM GIBSON D.D.S.

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	11555	TX

General Provider Information

NPI Number	:	1194868513
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD WILLIAM GIBSON D.D.S.

Provider Business Mailing Address
First Line	:	3210 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-0702
Country	:	US
Telephone Number	:	903-832-3146
Fax Number	:	903-838-2579

Provider Business Practice Location Address
First Line	:	3210 RICHMOND RD
Second Line	:
City	:	TEXARKANA
State	:	TX
Zip	:	75503-0702
Country	:	US
Telephone Number	:	903-832-3146
Fax Number	:	903-838-2579

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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