Provider Demographics
NPI:1063638310
Name:PHILLIPS, KEITH MARTIN (DMD, MSD)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:MARTIN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DMD, MSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5619 VALLEY AVE E
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98424-2060
Mailing Address - Country:US
Mailing Address - Phone:253-922-5519
Mailing Address - Fax:
Practice Address - Street 1:5619 VALLEY AVE E
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98424-2060
Practice Address - Country:US
Practice Address - Phone:253-922-5519
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2015-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA6023961041223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics