Provider Demographics
NPI:1902958887
Name:GIBSON, SUSAN BALLOU (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:BALLOU
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 HARDIN LN
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-3818
Mailing Address - Country:US
Mailing Address - Phone:606-678-9664
Mailing Address - Fax:606-679-1457
Practice Address - Street 1:110 HARDIN LN
Practice Address - Street 2:SUITE 2
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-3818
Practice Address - Country:US
Practice Address - Phone:606-678-9664
Practice Address - Fax:606-679-1457
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY62241223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics