Provider Demographics
NPI:1063557775
Name:PHILLIPS, ALDEN KEITH (DDS)
Entity type:Individual
Prefix:DR
First Name:ALDEN
Middle Name:KEITH
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1341 WESTGATE CENTER DR STE B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3043
Mailing Address - Country:US
Mailing Address - Phone:336-765-3712
Mailing Address - Fax:336-760-0667
Practice Address - Street 1:1341 WESTGATE CENTER DR STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3043
Practice Address - Country:US
Practice Address - Phone:336-765-3712
Practice Address - Fax:336-760-0667
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC57421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990155Medicaid