Basic Information
| Provider Information | |||||||||
| NPI: | 1437720190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RAY | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | MARTIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 874 GLENRAVEN DR | ||||||||
| Address2: | |||||||||
| City: | CLARKSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370438279 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6789952281 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3603 INDIANA AVE | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707983675 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2021 | ||||||||
| LastUpdateDate: | 07/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 1201 | TN | Y | Dental Providers | Dentist | General Practice |
No ID Information.