1255402616 NPI number — DR. YENDIS L GIBSON DDS

Table of content: DR. YENDIS L GIBSON DDS (NPI 1255402616)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255402616 NPI number — DR. YENDIS L GIBSON DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GIBSON
Provider First Name:
YENDIS
Provider Middle Name:
L
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GIBSON-KING
Provider Other First Name:
YENDIS
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1255402616
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
315 WOODLAWN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLENCOE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60022-2122
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3419 DEMPSTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SKOKIE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60076-2441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-568-1337
Provider Business Practice Location Address Fax Number:
847-568-1437
Provider Enumeration Date:
11/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  019017102 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 019017102 . This is a "STATE LICENSE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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