Provider Demographics
NPI:1760576920
Name:GERVAIS, PHILIP WILLIAM (DDS)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:WILLIAM
Last Name:GERVAIS
Suffix:
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 1:2005 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:SANDPOINT
Mailing Address - State:ID
Mailing Address - Zip Code:83864-9324
Mailing Address - Country:US
Mailing Address - Phone:208-263-8535
Mailing Address - Fax:208-265-2365
Practice Address - Street 1:2005 W PINE ST
Practice Address - Street 2:
Practice Address - City:SANDPOINT
Practice Address - State:ID
Practice Address - Zip Code:83864-9324
Practice Address - Country:US
Practice Address - Phone:208-263-8535
Practice Address - Fax:208-265-2365
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD17481223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice