Provider Demographics
NPI:1164408449
Name:PHILLIPS, DAVID M (DDS)
Entity Type:Individual
Prefix:
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 1:991 W HUDSON BLVD
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-6430
Mailing Address - Country:US
Mailing Address - Phone:704-853-5048
Mailing Address - Fax:704-671-1404
Practice Address - Street 1:991 W HUDSON BLVD
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28052-6430
Practice Address - Country:US
Practice Address - Phone:704-853-5048
Practice Address - Fax:704-671-1404
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC58771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8996864Medicaid