Provider Demographics
NPI:1316035033
Name:PHILLIPS, WALTER LEE (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:LEE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 FORT AVE
Mailing Address - Street 2:
Mailing Address - City:LYNCHBURG
Mailing Address - State:VA
Mailing Address - Zip Code:04502
Mailing Address - Country:US
Mailing Address - Phone:434-239-7411
Mailing Address - Fax:
Practice Address - Street 1:4700 FORT AVE
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:04502
Practice Address - Country:US
Practice Address - Phone:434-239-7411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0401-007471122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA196318OtherANTHEM