Provider Demographics
NPI:1548391444
Name:DRISCOLL, PHILIP G (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:G
Last Name:DRISCOLL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:PHILIP
Other - Middle Name:GREGORY
Other - Last Name:DRISCOLL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:BLACKFEET COMMUNITY HOSPITAL
Mailing Address - Street 2:P.O. BOX 760
Mailing Address - City:BROWNING
Mailing Address - State:MT
Mailing Address - Zip Code:59417
Mailing Address - Country:US
Mailing Address - Phone:406-338-6180
Mailing Address - Fax:
Practice Address - Street 1:BLACKFEET COMMUNITY HOSPITAL
Practice Address - Street 2:GOVERNMENT SQUARE
Practice Address - City:BROWNING
Practice Address - State:MT
Practice Address - Zip Code:59417
Practice Address - Country:US
Practice Address - Phone:406-338-6180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA42741223D0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223D0001XDental ProvidersDentistDental Public Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4274OtherSTATE DENTAL LICENSE