Provider Demographics
NPI:1033234273
Name:PERRY, PHILLIP G (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:G
Last Name:PERRY
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 1:1000 HIAWATHA DR E
Mailing Address - Street 2:
Mailing Address - City:WABASHA
Mailing Address - State:MN
Mailing Address - Zip Code:55981-1733
Mailing Address - Country:US
Mailing Address - Phone:651-565-2888
Mailing Address - Fax:651-565-2882
Practice Address - Street 1:1000 HIAWATHA DR E
Practice Address - Street 2:
Practice Address - City:WABASHA
Practice Address - State:MN
Practice Address - Zip Code:55981-1733
Practice Address - Country:US
Practice Address - Phone:651-565-2888
Practice Address - Fax:651-565-2882
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN99631223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice