Provider Demographics
NPI:1154808780
Name:LYBBERT, BRADY GLENN (DMD)
Entity type:Individual
Prefix:DR
First Name:BRADY
Middle Name:GLENN
Last Name:LYBBERT
Suffix:
Gender:M
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:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:SACATON
Mailing Address - State:AZ
Mailing Address - Zip Code:85147-0001
Mailing Address - Country:US
Mailing Address - Phone:602-528-1200
Mailing Address - Fax:620-528-1255
Practice Address - Street 1:1005 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85256
Practice Address - Country:US
Practice Address - Phone:480-946-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-26
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10848090-99221223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice