Provider Demographics
NPI:1902949969
Name:LOWDER, PHILLIP DAVID (DDS, MCLD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:DAVID
Last Name:LOWDER
Suffix:
Gender:M
Credentials:DDS, MCLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 SHELL FLOWER RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-8049
Mailing Address - Country:US
Mailing Address - Phone:702-451-4205
Mailing Address - Fax:
Practice Address - Street 1:250 SOUTH SKYINE DRIVE
Practice Address - Street 2:STE 4
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83402
Practice Address - Country:US
Practice Address - Phone:208-524-1404
Practice Address - Fax:208-524-1114
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVS31001223X0400X
IDD3600-OR1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics