Provider Demographics
NPI:1487676888
Name:HANEY, PHILIP CARL (DDS, FAGD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:CARL
Last Name:HANEY
Suffix:
Gender:M
Credentials:DDS, FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E MESCALERO RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-6510
Mailing Address - Country:US
Mailing Address - Phone:505-623-9110
Mailing Address - Fax:505-623-6436
Practice Address - Street 1:203 E MESCALERO RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-6510
Practice Address - Country:US
Practice Address - Phone:505-623-9110
Practice Address - Fax:505-623-6436
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD16361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice