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General NPI Number Information
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NPI Number | 1639381429
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Entity Type | Organization
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Legal Business Name | PHYLLIS PENDERGRAST, D.M.D., A.P.C.
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Dates
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Enumeration Date | 05/04/2007
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Last Update Date | 10/22/2014
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Provider Practice Location Address
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Address Line | 3539 THOMAS ST.
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City | FAIRBANKS
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State | AK
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Zip | 99709-3833
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Country | US
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Telephone | 907-452-7041
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Fax | 907-451-7166
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Provider Business Mailing Address
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Address Line | 3539 THOMAS ST.
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City | FAIRBANKS
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State | AK
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Zip | 99709-3833
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Country | US
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Telephone | 907-452-7041
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Fax | 907-451-7166
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Authorized Official
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Title or Position | DOCTOR
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Name | DR. PHYLLIS L PENDERGRAST
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Credential | D.M.D,
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Telephone | 907-457-6145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 477
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License Number State | AK
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