1780756122 NPI number — PHILLIP R PATE DDS

Table of content: PHILLIP R PATE DDS (NPI 1780756122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780756122 NPI number — PHILLIP R PATE DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PATE
Provider First Name:
PHILLIP
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1780756122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2705 S BERKLEY
Provider Second Line Business Mailing Address:
BUILDING 2 SUITE B
Provider Business Mailing Address City Name:
KOKOMO
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46902-8007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-453-2267
Provider Business Mailing Address Fax Number:
765-453-1150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2705 S BERKLEY
Provider Second Line Business Practice Location Address:
BUILDING 2 SUITE B
Provider Business Practice Location Address City Name:
KOKOMO
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46902-8007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-453-2267
Provider Business Practice Location Address Fax Number:
765-453-1150
Provider Enumeration Date:
11/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  6519 , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6519 . This is a "DENTAL LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".




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