Healthcare Provider Details

I. General information

NPI: 1013073378
Provider Name (Legal Business Name): GIPSON MARK KINGRY D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8101 SEATON PL. SUITE A
MONTGOMERY AL
36116-7205
US

IV. Provider business mailing address

8101 SEATON PL. STE. A
MONTGOMERY AL
36116-7205
US

V. Phone/Fax

Practice location:
  • Phone: 334-272-4900
  • Fax: 334-409-9933
Mailing address:
  • Phone: 334-272-4900
  • Fax: 334-409-9933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4440
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: