Provider Demographics
NPI:1245229202
Name:PHILLIPS, WILLIAM A (DMD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
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 1:1001 DUPONT SQ N
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4612
Mailing Address - Country:US
Mailing Address - Phone:502-897-0625
Mailing Address - Fax:502-897-0627
Practice Address - Street 1:1001 DUPONT SQ N
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4612
Practice Address - Country:US
Practice Address - Phone:502-897-0625
Practice Address - Fax:502-897-0627
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-20
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY040171223P0221X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY60040177Medicaid
KY45602125Medicaid