Provider Demographics
NPI:1992765366
Name:DEVORE, PHILLIP RUSSELL (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:RUSSELL
Last Name:DEVORE
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 1:1001 SHADOW LANE MS 7413
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89106
Mailing Address - Country:US
Mailing Address - Phone:702-774-8000
Mailing Address - Fax:702-774-2812
Practice Address - Street 1:1700 W CHARLESTON BLDG D
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102
Practice Address - Country:US
Practice Address - Phone:702-774-8000
Practice Address - Fax:702-774-2812
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV42851223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV200538965OtherTIN