Provider Demographics
NPI:1457546749
Name:PHILLIPS, KEITH ALEXANDER (DDS)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:ALEXANDER
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:KEITH
Other - Middle Name:ALEXANDER
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:PO BOX 130143
Mailing Address - Street 2:
Mailing Address - City:LAURELTON
Mailing Address - State:NY
Mailing Address - Zip Code:11413-0143
Mailing Address - Country:US
Mailing Address - Phone:718-291-9117
Mailing Address - Fax:718-291-9117
Practice Address - Street 1:10753 GUY R BREWER BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-2351
Practice Address - Country:US
Practice Address - Phone:718-291-9117
Practice Address - Fax:718-291-9117
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0288461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00290359Medicaid