Provider Demographics
NPI:1366533283
Name:ROBY, DARYL (DMD)
Entity type:Individual
Prefix:MR
First Name:DARYL
Middle Name:
Last Name:ROBY
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 1:15423 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:DURANT
Mailing Address - State:MS
Mailing Address - Zip Code:39063-4003
Mailing Address - Country:US
Mailing Address - Phone:662-653-3880
Mailing Address - Fax:662-653-3890
Practice Address - Street 1:15423 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:MS
Practice Address - Zip Code:39063-4003
Practice Address - Country:US
Practice Address - Phone:662-653-3880
Practice Address - Fax:662-653-3890
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS283794122300000X
GADNO14632122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00660253Medicaid