Provider Demographics
NPI:1104154111
Name:PHIPPEN, ROSS SPENCER JR (DMD)
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:SPENCER
Last Name:PHIPPEN
Suffix:JR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MAIDEN LN
Mailing Address - Street 2:PO BOX 423
Mailing Address - City:PENN YAN
Mailing Address - State:NY
Mailing Address - Zip Code:14527-1208
Mailing Address - Country:US
Mailing Address - Phone:315-531-9102
Mailing Address - Fax:315-531-9103
Practice Address - Street 1:160 MAIN ST
Practice Address - Street 2:
Practice Address - City:PENN YAN
Practice Address - State:NY
Practice Address - Zip Code:14527-1204
Practice Address - Country:US
Practice Address - Phone:315-536-2024
Practice Address - Fax:315-536-4005
Is Sole Proprietor?:No
Enumeration Date:2009-12-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY058846122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY058689OtherLICENSE
NY04559624Medicaid
NY04559624Medicaid