Provider Demographics
NPI:1396026209
Name:PHILLIPS DENTISTRY, PS.
Entity Type:Organization
Organization Name:PHILLIPS DENTISTRY, PS.
Other - Org Name:DISTINCTIVE DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MSD
Authorized Official - Phone:253-922-6822
Mailing Address - Street 1:5615 VALLEY AVE E
Mailing Address - Street 2:
Mailing Address - City:FIFE
Mailing Address - State:WA
Mailing Address - Zip Code:98424-2060
Mailing Address - Country:US
Mailing Address - Phone:253-922-6822
Mailing Address - Fax:253-922-3513
Practice Address - Street 1:5615 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:253-922-6822
Practice Address - Fax:253-922-3513
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-06
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QD0000X
WA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental