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General NPI Number Information
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NPI Number | 1205094117
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Entity Type | Individual
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Provider Name | PHATTARA GIBBS DMD
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Gender | Male
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Dates
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Enumeration Date | 05/28/2008
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Last Update Date | 11/03/2009
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Provider Practice Location Address
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Address Line | 4744 S FLORIDA AVE
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City | LAKELAND
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State | FL
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Zip | 33813-2181
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Country | US
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Telephone | 863-644-1226
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Fax | 863-644-3756
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Provider Business Mailing Address
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Address Line | 5801 S MACDILL AVE UNIT 14
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City | TAMPA
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State | FL
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Zip | 33611-4482
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Country | US
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Telephone | 813-368-3984
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Fax | 863-644-3756
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | DN18269
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License Number State | FL
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