Provider Demographics
NPI:1154311181
Name:PHILLIPS, DAVID M (DDS)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:M
Last Name:PHILLIPS
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 1:1406 OSCEOLA AVE
Mailing Address - Street 2:APT #204
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-2348
Mailing Address - Country:US
Mailing Address - Phone:651-207-8780
Mailing Address - Fax:
Practice Address - Street 1:11237 FOLEY BLVD NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55448-3389
Practice Address - Country:US
Practice Address - Phone:763-757-3120
Practice Address - Fax:763-757-5161
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2014-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND111141223G0001X, 1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery