Provider Demographics
NPI:1861808487
Name:GIBSON, MCKENNA RHEA (DMD)
Entity type:Individual
Prefix:DR
First Name:MCKENNA
Middle Name:RHEA
Last Name:GIBSON
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:MCKENNA
Other - Middle Name:ASHLI
Other - Last Name:RHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10871 COUNTY LINE RD STE A
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:AL
Mailing Address - Zip Code:35758-3668
Mailing Address - Country:US
Mailing Address - Phone:256-724-3530
Mailing Address - Fax:
Practice Address - Street 1:10871 COUNTY LINE RD STE A
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:AL
Practice Address - Zip Code:35758
Practice Address - Country:US
Practice Address - Phone:256-724-3530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6232122300000X, 1223G0001X
TX302621223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist