Basic Information
| Provider Information | |||||||||
| NPI: | 1417911496 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GIBSON | ||||||||
| FirstName: | JAN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 215 SHERIDAN RD | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799063803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2532839106 | ||||||||
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| Practice Location | |||||||||
| Address1: | BLDG 128 CHAFFEE RD, US ARMY DENTAL ACTIVITY | ||||||||
| Address2: | ATTN: DENTAC HEADQUEARTERS | ||||||||
| City: | FORT BLISS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9157426001 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2006 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 6445 | WA | Y | Dental Providers | Dental Hygienist |
No ID Information.