Provider Demographics
NPI:1780756122
Name:PATE, PHILLIP R (DDS)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:R
Last Name:PATE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2705 S BERKLEY
Mailing Address - Street 2:BUILDING 2 SUITE B
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-8007
Mailing Address - Country:US
Mailing Address - Phone:765-453-2267
Mailing Address - Fax:765-453-1150
Practice Address - Street 1:2705 S BERKLEY
Practice Address - Street 2:BUILDING 2 SUITE B
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-8007
Practice Address - Country:US
Practice Address - Phone:765-453-2267
Practice Address - Fax:765-453-1150
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN65191223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN6519OtherDENTAL LICENSE