Provider Demographics
NPI:1487715215
Name:GIBBS ACOSTA, LYDIA M (DMD)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:M
Last Name:GIBBS ACOSTA
Suffix:
Gender:F
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:CALLE 2 C 5
Mailing Address - Street 2:URB SANTA PAULA
Mailing Address - City:GUAYNABO
Mailing Address - State:PR
Mailing Address - Zip Code:00969
Mailing Address - Country:US
Mailing Address - Phone:787-789-7257
Mailing Address - Fax:
Practice Address - Street 1:CALLE SANTA CRUZ #59
Practice Address - Street 2:
Practice Address - City:BAYAMON
Practice Address - State:PR
Practice Address - Zip Code:00961
Practice Address - Country:US
Practice Address - Phone:787-786-4180
Practice Address - Fax:787-786-5723
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1601122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist