Provider Demographics
NPI:1861597718
Name:PHILLIPS, HAYDEN R (DMD)
Entity type:Individual
Prefix:
First Name:HAYDEN
Middle Name:R
Last Name:PHILLIPS
Suffix:
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 1:1012 IVAL JAMES BLVD
Mailing Address - Street 2:C
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-8174
Mailing Address - Country:US
Mailing Address - Phone:859-626-9620
Mailing Address - Fax:859-626-9622
Practice Address - Street 1:1012 IVAL JAMES BLVD
Practice Address - Street 2:C
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-8174
Practice Address - Country:US
Practice Address - Phone:859-626-9620
Practice Address - Fax:859-626-9622
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2015-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY79821223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1500OtherBLUE CROSS/BLUE SHIELD ID
KY61901088Medicaid
KY60003282Medicaid
KY61901211Medicaid
KY7982OtherDELTA DENTAL ID#