Provider Demographics
NPI:1134138423
Name:FRIST, PHILLIP STANLEY (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:STANLEY
Last Name:FRIST
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 1:714 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46012-3450
Mailing Address - Country:US
Mailing Address - Phone:765-649-0611
Mailing Address - Fax:765-649-0835
Practice Address - Street 1:714 WALNUT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46012-3450
Practice Address - Country:US
Practice Address - Phone:765-649-0611
Practice Address - Fax:765-649-0835
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN12007236A1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice