Provider Demographics
NPI:1053332379
Name:GARY SELBY DDS PA
Entity Type:Organization
Organization Name:GARY SELBY DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ROYAL
Authorized Official - Last Name:SELBY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:813-654-0037
Mailing Address - Street 1:122 LAUREL TREE WAY
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-8030
Mailing Address - Country:US
Mailing Address - Phone:813-654-0037
Mailing Address - Fax:813-654-0227
Practice Address - Street 1:410 W BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-7402
Practice Address - Country:US
Practice Address - Phone:813-654-0037
Practice Address - Fax:813-654-0227
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL57771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty