Healthcare Provider Details

I. General information

NPI: 1942477609
Provider Name (Legal Business Name): PAUL ROBERT GIBBS DDS MS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 05/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 S MAIN ST BUILDING 300 SUITE 301
DAVIDSON NC
28036
US

IV. Provider business mailing address

PO BOX 2241 460 S MAIN ST BUILDING 300 SUITE 301
DAVIDSON NC
28036
US

V. Phone/Fax

Practice location:
  • Phone: 704-892-0644
  • Fax: 704-892-6617
Mailing address:
  • Phone: 704-892-0644
  • Fax: 704-892-6617

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number6435
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: