Provider Demographics
NPI:1285653378
Name:PHILIPOVITCH, DIMITRY TIMOTHY (DDS)
Entity Type:Individual
Prefix:DR
First Name:DIMITRY
Middle Name:TIMOTHY
Last Name:PHILIPOVITCH
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 1:3601 SPRINGBROOK ST
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75205-4338
Mailing Address - Country:US
Mailing Address - Phone:415-519-7374
Mailing Address - Fax:
Practice Address - Street 1:2813 COFFEE RD STE B2
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-1755
Practice Address - Country:US
Practice Address - Phone:209-526-4884
Practice Address - Fax:209-526-6133
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA403861223G0001X
TX29435122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist