Healthcare Provider Details

I. General information

NPI: 1255505277
Provider Name (Legal Business Name): THOMAS J GIBBONS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TOM J GIBBONS DDS

II. Dates (important events)

Enumeration Date: 04/22/2008
Last Update Date: 04/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 S MAIN ST
WESTBY WI
54667
US

IV. Provider business mailing address

701 S MAIN ST
WESTBY WI
54667
US

V. Phone/Fax

Practice location:
  • Phone: 608-634-3978
  • Fax: 608-634-6205
Mailing address:
  • Phone: 608-634-3978
  • Fax: 608-634-6205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number3144
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: