MEDICARE: DR. PHATTARA GIBBS DMD

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	122300000X	Dentist	DN18269	FL

General Provider Information

NPI Number	:	1205094117
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHATTARA GIBBS DMD

Provider Business Mailing Address
First Line	:	5801 S MACDILL AVE UNIT 14
Second Line	:
City	:	TAMPA
State	:	FL
Zip	:	33611-4482
Country	:	US
Telephone Number	:	813-368-3984
Fax Number	:	863-644-3756

Provider Business Practice Location Address
First Line	:	4744 S FLORIDA AVE
Second Line	:
City	:	LAKELAND
State	:	FL
Zip	:	33813-2181
Country	:	US
Telephone Number	:	863-644-1226
Fax Number	:	863-644-3756

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

Provider Enumeration Date	:	05/28/2008
Last Update Date	:	11/03/2009

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