Provider Demographics
NPI:1427707306
Name:STORRUD, PHILIP SAMUEL (DDS)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:SAMUEL
Last Name:STORRUD
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 1:3090 TALON DR
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-3378
Mailing Address - Country:US
Mailing Address - Phone:307-237-1801
Mailing Address - Fax:307-237-3686
Practice Address - Street 1:3090 TALON DR
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-3378
Practice Address - Country:US
Practice Address - Phone:307-231-1801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-19
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY16071223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice