Provider Demographics
NPI:1396123030
Name:SYBERT, ELYSIA (DDS)
Entity type:Individual
Prefix:
First Name:ELYSIA
Middle Name:
Last Name:SYBERT
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2115 SE 192ND AVE STE 106
Mailing Address - Street 2:
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-7444
Mailing Address - Country:US
Mailing Address - Phone:360-216-1130
Mailing Address - Fax:
Practice Address - Street 1:2115 SE 192ND AVE STE 106
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-7444
Practice Address - Country:US
Practice Address - Phone:360-216-1130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-14
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC9245122300000X
CA65090122300000X
ORD111961223P0221X
WADE.610452801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist