Provider Demographics
NPI:1639381429
Name:PHYLLIS PENDERGRAST, D.M.D., A.P.C.
Entity Type:Organization
Organization Name:PHYLLIS PENDERGRAST, D.M.D., A.P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:L
Authorized Official - Last Name:PENDERGRAST
Authorized Official - Suffix:
Authorized Official - Credentials:DMD,
Authorized Official - Phone:907-457-6145
Mailing Address - Street 1:3539 THOMAS ST.
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3833
Mailing Address - Country:US
Mailing Address - Phone:907-452-7041
Mailing Address - Fax:907-451-7166
Practice Address - Street 1:3539 THOMAS ST.
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3833
Practice Address - Country:US
Practice Address - Phone:907-452-7041
Practice Address - Fax:907-451-7166
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-04
Last Update Date:2014-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK477122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty