Provider Demographics
NPI:1982625323
Name:SELBY, GARY ROYAL (DDS)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ROYAL
Last Name:SELBY
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 1:122 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL57771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice