Provider Demographics
NPI:1205094117
Name:GIBBS, PHATTARA (DMD)
Entity type:Individual
Prefix:DR
First Name:PHATTARA
Middle Name:
Last Name:GIBBS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5801 S MACDILL AVE UNIT 14
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33611-4482
Mailing Address - Country:US
Mailing Address - Phone:813-368-3984
Mailing Address - Fax:863-644-3756
Practice Address - Street 1:4744 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33813-2181
Practice Address - Country:US
Practice Address - Phone:863-644-1226
Practice Address - Fax:863-644-3756
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-28
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN18269122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist