Healthcare Provider Details

I. General information

NPI: 1497091243
Provider Name (Legal Business Name): KEITH PHILLIPS, DMD, MSD, PS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5619 VALLEY AVE E
FIFE WA
98424-2060
US

IV. Provider business mailing address

5619 VALLEY AVE E
FIFE WA
98424-2060
US

V. Phone/Fax

Practice location:
  • Phone: 253-922-5519
  • Fax: 253-922-2719
Mailing address:
  • Phone: 253-922-5519
  • Fax: 253-922-2719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License NumberDE00007693
License Number StateWA

VIII. Authorized Official

Name: DR. KEITH MARTIN PHILLIPS
Title or Position: OWNER
Credential: DMD, MSD
Phone: 253-922-5519