Provider Demographics
NPI:1457765471
Name:PENDERGRAST, PHYLLIS LYNN (DMD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:LYNN
Last Name:PENDERGRAST
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:MISS
Other - First Name:PHYLLIS
Other - Middle Name:LYNN
Other - Last Name:EVERHARDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3539 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709
Mailing Address - Country:US
Mailing Address - Phone:907-452-7041
Mailing Address - Fax:907-451-7166
Practice Address - Street 1:3539 THOMAS ST
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709
Practice Address - Country:US
Practice Address - Phone:907-452-7041
Practice Address - Fax:907-451-7166
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK0477122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist