Provider Demographics
NPI:1023454071
Name:GAMBILL, MICAHEL JASON (DDS)
Entity type:Individual
Prefix:DR
First Name:MICAHEL
Middle Name:JASON
Last Name:GAMBILL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2285 BENTON RD STE C100
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-3465
Mailing Address - Country:US
Mailing Address - Phone:318-742-9333
Mailing Address - Fax:318-747-9089
Practice Address - Street 1:2285 BENTON RD STE C100
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3465
Practice Address - Country:US
Practice Address - Phone:318-742-9333
Practice Address - Fax:318-747-9089
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2018-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO002019591223P0221X
LA64221223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA30872Medicaid