Provider Demographics
NPI:1053445577
Name:EDGERTON, PHILIP B (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:B
Last Name:EDGERTON
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CALLE MEDICO
Mailing Address - Street 2:SUITE-A
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4762
Mailing Address - Country:US
Mailing Address - Phone:505-988-3209
Mailing Address - Fax:505-988-7513
Practice Address - Street 1:5 CALLE MEDICO
Practice Address - Street 2:SUITE-A
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4762
Practice Address - Country:US
Practice Address - Phone:505-988-3209
Practice Address - Fax:505-988-7513
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM12341223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics