Provider Demographics
NPI:1205011376
Name:HARAM, PHILLIP JAMES (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:JAMES
Last Name:HARAM
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 1:128 MARKET STREET
Mailing Address - Street 2:
Mailing Address - City:ALAMOSA
Mailing Address - State:CO
Mailing Address - Zip Code:81101
Mailing Address - Country:US
Mailing Address - Phone:719-589-5161
Mailing Address - Fax:719-589-5722
Practice Address - Street 1:128 MARKET STREET
Practice Address - Street 2:
Practice Address - City:ALAMOSA
Practice Address - State:CO
Practice Address - Zip Code:81101
Practice Address - Country:US
Practice Address - Phone:719-589-9691
Practice Address - Fax:719-587-9148
Is Sole Proprietor?:No
Enumeration Date:2008-01-08
Last Update Date:2008-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO788122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO02007888Medicaid