Provider Demographics
NPI:1114127701
Name:PHILLIPS, CAROL LYNN (DDS)
Entity Type:Individual
Prefix:DR
First Name:CAROL
Middle Name:LYNN
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3046 S HIGUERA ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-6622
Mailing Address - Country:US
Mailing Address - Phone:805-541-1004
Mailing Address - Fax:805-541-2523
Practice Address - Street 1:3046 S HIGUERA ST
Practice Address - Street 2:SUITE C
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-6622
Practice Address - Country:US
Practice Address - Phone:805-541-1004
Practice Address - Fax:805-541-2523
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-20
Last Update Date:2007-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD-25359122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist