Provider Demographics
NPI:1912183849
Name:DR JONATHAN R PHIPPS DMD PC
Entity Type:Organization
Organization Name:DR JONATHAN R PHIPPS DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:PHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:505-836-0322
Mailing Address - Street 1:6400 CENTRAL AVE SW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87105-2033
Mailing Address - Country:US
Mailing Address - Phone:505-836-0322
Mailing Address - Fax:505-836-2040
Practice Address - Street 1:6400 CENTRAL AVE SW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87105-2033
Practice Address - Country:US
Practice Address - Phone:505-836-0322
Practice Address - Fax:505-836-2040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM14201223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty