Provider Demographics
NPI:1083715353
Name:BLY, PHILLIP MURRAY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:MURRAY
Last Name:BLY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7126 N SHADELAND AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250
Mailing Address - Country:US
Mailing Address - Phone:317-842-6402
Mailing Address - Fax:317-842-6403
Practice Address - Street 1:7126 N SHADELAND AVE
Practice Address - Street 2:SUITE B
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250
Practice Address - Country:US
Practice Address - Phone:317-842-6402
Practice Address - Fax:317-842-6403
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007762A122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist