Provider Demographics
NPI:1912196882
Name:ELLIOTT, PHILLIP JAMES (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:JAMES
Last Name:ELLIOTT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:J
Other - Last Name:ELLIOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:HATCH
Mailing Address - State:NM
Mailing Address - Zip Code:87937-0370
Mailing Address - Country:US
Mailing Address - Phone:575-267-3280
Mailing Address - Fax:575-267-1747
Practice Address - Street 1:1600 THORPE RD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88012-9776
Practice Address - Country:US
Practice Address - Phone:575-382-9292
Practice Address - Fax:575-382-2061
Is Sole Proprietor?:No
Enumeration Date:2007-10-17
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2293122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist