Provider Demographics
NPI:1487264446
Name:IRBY, AMBER NICHELLE (MDT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:NICHELLE
Last Name:IRBY
Suffix:
Gender:F
Credentials:MDT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 BRITTANY LN NW APT C
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-7012
Mailing Address - Country:US
Mailing Address - Phone:757-218-8082
Mailing Address - Fax:
Practice Address - Street 1:903 W CENTER ST #130
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55902
Practice Address - Country:US
Practice Address - Phone:507-529-0436
Practice Address - Fax:507-529-0435
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDT129125J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125J00000XDental ProvidersDental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA