Provider Demographics
NPI:1063919744
Name:KEPHART, PHYLLIS (PHDHP)
Entity type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:KEPHART
Suffix:
Gender:F
Credentials:PHDHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 52ND ST
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16602-1446
Mailing Address - Country:US
Mailing Address - Phone:814-943-3606
Mailing Address - Fax:
Practice Address - Street 1:501 HOWARD AVE.
Practice Address - Street 2:BUILDING D SUITE 103
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4814
Practice Address - Country:US
Practice Address - Phone:814-889-6420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPHDH000805124Q00000X
PADH010609L124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes124Q00000XDental ProvidersDental Hygienist