Provider Demographics
NPI:1902214604
Name:PARKER, PHILLIP (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:PARKER
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 1:24 TWIN PONDS DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-6432
Mailing Address - Country:US
Mailing Address - Phone:845-338-2999
Mailing Address - Fax:
Practice Address - Street 1:3669 MAIN ST
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5613
Practice Address - Country:US
Practice Address - Phone:845-687-0066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY040 171 1125K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes125K00000XDental ProvidersAdvanced Practice Dental Therapist