Healthcare Provider Details

I. General information

NPI: 1508072877
Provider Name (Legal Business Name): EDITH S GIBSON RDH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 09/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26216 HIGHWAY 135
CRESTED BUTTE CO
81224
US

IV. Provider business mailing address

PO BOX 13
CRESTED BUTTE CO
81224-0013
US

V. Phone/Fax

Practice location:
  • Phone: 970-596-4458
  • Fax:
Mailing address:
  • Phone: 970-596-4458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberDH-904336
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: