Provider Demographics
NPI:1154312437
Name:HEAD, PHILLIP WAYNE SR (DDS CAGS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WAYNE
Last Name:HEAD
Suffix:SR
Gender:M
Credentials:DDS CAGS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 TROTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:TN
Mailing Address - Zip Code:38401-4750
Mailing Address - Country:US
Mailing Address - Phone:931-388-5627
Mailing Address - Fax:931-381-6797
Practice Address - Street 1:1324 TROTWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:TN
Practice Address - Zip Code:38401-4750
Practice Address - Country:US
Practice Address - Phone:931-388-5627
Practice Address - Fax:931-381-6797
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS39131223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics