MEDICARE: DR. LAURENCE O GIBBONS JR. DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	DEN3068	DC

General Provider Information

NPI Number	:	1861616831
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LAURENCE O GIBBONS JR. DDS

Provider Business Mailing Address
First Line	:	4303 16TH STREET NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20011-7011
Country	:	US
Telephone Number	:	202-723-2266
Fax Number	:

Provider Business Practice Location Address
First Line	:	4303 16TH STREET NW
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20011-7011
Country	:	US
Telephone Number	:	202-723-2266
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2007
Last Update Date	:	07/08/2007

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