Healthcare Provider Details

I. General information

NPI: 1205094117
Provider Name (Legal Business Name): PHATTARA GIBBS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2008
Last Update Date: 11/03/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4744 S FLORIDA AVE
LAKELAND FL
33813-2181
US

IV. Provider business mailing address

5801 S MACDILL AVE UNIT 14
TAMPA FL
33611-4482
US

V. Phone/Fax

Practice location:
  • Phone: 863-644-1226
  • Fax: 863-644-3756
Mailing address:
  • Phone: 813-368-3984
  • Fax: 863-644-3756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN18269
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: