Healthcare Provider Details

I. General information

NPI: 1174730287
Provider Name (Legal Business Name): REX SHANNON GIBSON D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2007
Last Update Date: 01/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 SE 3RD ST STE #A-1
BEND OR
97702-2161
US

IV. Provider business mailing address

63870 JOHNSON RD
BEND OR
97701-5218
US

V. Phone/Fax

Practice location:
  • Phone: 541-318-5688
  • Fax: 541-322-5581
Mailing address:
  • Phone: 541-318-5688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberD7724
License Number StateOR

VII. Legacy identifiers

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

# 1
Identifier299183
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: