Provider Demographics
NPI:1902680200
Name:GIBSON, DALLAS NATHANIEL
Entity Type:Individual
Prefix:DR
First Name:DALLAS
Middle Name:NATHANIEL
Last Name:GIBSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4935 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-2735
Mailing Address - Country:US
Mailing Address - Phone:615-302-4068
Mailing Address - Fax:
Practice Address - Street 1:4935 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-2735
Practice Address - Country:US
Practice Address - Phone:615-302-4068
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN47466183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist