Provider Demographics
NPI:1497091243
Name:KEITH PHILLIPS, DMD, MSD, PS, INC
Entity Type:Organization
Organization Name:KEITH PHILLIPS, DMD, MSD, PS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
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:253-922-5519
Mailing Address - Street 1:5619 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:253-922-5519
Mailing Address - Fax:253-922-2719
Practice Address - Street 1:5619 VALLEY AVE E
Practice Address - Street 2:
Practice Address - City:FIFE
Practice Address - State:WA
Practice Address - Zip Code:98424-2060
Practice Address - Country:US
Practice Address - Phone:253-922-5519
Practice Address - Fax:253-922-2719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-26
Last Update Date:2012-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE00007693261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental