Provider Demographics
NPI:1245510155
Name:LIBBY, JUSTIN (DDS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:LIBBY
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 1:3920 LAKE OTIS PKWY
Mailing Address - Street 2:SUITE A
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5210
Mailing Address - Country:US
Mailing Address - Phone:907-274-2659
Mailing Address - Fax:907-277-4782
Practice Address - Street 1:3920 LAKE OTIS PKWY
Practice Address - Street 2:SUITE A
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5210
Practice Address - Country:US
Practice Address - Phone:907-274-2659
Practice Address - Fax:907-277-4782
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2013-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT8029310122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist