Provider Demographics
NPI:1053304238
Name:HUCKANS, PHILLIP RICHARD (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:RICHARD
Last Name:HUCKANS
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 1:2109 N PINOS ALTOS RD
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-7866
Mailing Address - Country:US
Mailing Address - Phone:505-534-1133
Mailing Address - Fax:505-534-1144
Practice Address - Street 1:2109 N PINOS ALTOS RD
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-7866
Practice Address - Country:US
Practice Address - Phone:505-534-1133
Practice Address - Fax:505-534-1144
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD18981223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMQ2382Medicaid