Provider Demographics
NPI:1497891790
Name:LORENZ, PHILLIP HERBERT SR (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:HERBERT
Last Name:LORENZ
Suffix:SR
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 1:2200 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-4151
Mailing Address - Country:US
Mailing Address - Phone:307-635-5560
Mailing Address - Fax:307-772-7304
Practice Address - Street 1:2200 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-4151
Practice Address - Country:US
Practice Address - Phone:307-635-5560
Practice Address - Fax:307-772-7304
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1524775OtherUNITED CONCORDIA
WY313462OtherBCBS