Provider Demographics
NPI:1124123005
Name:LIBBY, GREGORY A (DDS)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:A
Last Name:LIBBY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20950 N TATUM BLVD STE 340
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-4256
Mailing Address - Country:US
Mailing Address - Phone:480-502-9833
Mailing Address - Fax:480-502-9847
Practice Address - Street 1:20950 N TATUM BLVD STE 340
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-4256
Practice Address - Country:US
Practice Address - Phone:480-502-9833
Practice Address - Fax:480-502-9847
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ54571223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics