Provider Demographics
NPI:1235359944
Name:LATHAM, PHILIP GLENN (DDS)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:GLENN
Last Name:LATHAM
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 1:5070 FOOTHILLS BLVD # 2
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-6500
Mailing Address - Country:US
Mailing Address - Phone:916-781-2611
Mailing Address - Fax:916-781-2760
Practice Address - Street 1:5070 FOOTHILLS BLVD # 2
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-6500
Practice Address - Country:US
Practice Address - Phone:916-781-2611
Practice Address - Fax:916-781-2760
Is Sole Proprietor?:No
Enumeration Date:2007-04-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA357511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice