Provider Demographics
NPI:1013297332
Name:BRIGDEN, PHILLIP TRACY (DDS)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:TRACY
Last Name:BRIGDEN
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 1:11919 GRANT ST STE 140
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-3475
Mailing Address - Country:US
Mailing Address - Phone:402-493-4175
Mailing Address - Fax:
Practice Address - Street 1:11919 GRANT ST STE 140
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68164-3475
Practice Address - Country:US
Practice Address - Phone:402-493-4175
Practice Address - Fax:877-811-8129
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE5969122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist