=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013193465
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | W.SIDNEY GIBSON, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2008
-----------------------------------------------------
Last Update Date | 01/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 904 SPIVEY RD
-----------------------------------------------------
City | WHITEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28472-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-642-7741
-----------------------------------------------------
Fax | 910-640-2373
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 904 SPIVEY RD
-----------------------------------------------------
City | WHITEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28472-2915
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-642-7741
-----------------------------------------------------
Fax | 910-640-2373
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RECEPTIONIST
-----------------------------------------------------
Name | MISS WENDY GRICE BULLARD
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 910-642-7741
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 3921
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------