Healthcare Provider Details

I. General information

NPI: 1538167234
Provider Name (Legal Business Name): MICHAEL J GIBBONS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7477 E DOUBLETREE RANCH RD SUITE 200
SCOTTSDALE AZ
85258-2048
US

IV. Provider business mailing address

11111 N SCOTTSDALE RD STE 220
SCOTTSDALE AZ
85254-6732
US

V. Phone/Fax

Practice location:
  • Phone: 480-368-0060
  • Fax: 480-443-1869
Mailing address:
  • Phone: 480-368-0060
  • Fax: 480-443-1869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberD2139
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: