Provider Demographics
NPI:1952450686
Name:SINCLAIR, PHEONIX ELLIS (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHEONIX
Middle Name:ELLIS
Last Name:SINCLAIR
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 1:3335 ROLLS DR
Mailing Address - Street 2:
Mailing Address - City:CAMERON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:95682-9246
Mailing Address - Country:US
Mailing Address - Phone:530-676-7197
Mailing Address - Fax:530-676-7198
Practice Address - Street 1:4140 MOTHER LODE DR
Practice Address - Street 2:SUITE 112
Practice Address - City:SHINGLE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95682-8038
Practice Address - Country:US
Practice Address - Phone:530-672-8059
Practice Address - Fax:530-672-2111
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD258411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CATHP70630FMedicaid
CAD25841OtherDENTAL