Provider Demographics
NPI:1063575967
Name:BROCKINGTON, PHILLIP MAURICE (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:MAURICE
Last Name:BROCKINGTON
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 1:6724 TROOST AVE
Mailing Address - Street 2:SUITE 407
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64131-1501
Mailing Address - Country:US
Mailing Address - Phone:816-333-2455
Mailing Address - Fax:
Practice Address - Street 1:6724 TROOST AVE
Practice Address - Street 2:SUITE 407
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64131-1501
Practice Address - Country:US
Practice Address - Phone:816-333-2455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1688731223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400586103Medicaid