Healthcare Provider Details

I. General information

NPI: 1063638310
Provider Name (Legal Business Name): KEITH MARTIN PHILLIPS D.M.D., M.S.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 11/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5619 VALLEY AVE E
TACOMA WA
98424-2060
US

IV. Provider business mailing address

5619 VALLEY AVE E
TACOMA WA
98424-2060
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number602396104
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: