Provider Demographics
NPI:1316197007
Name:PHILLIP, JEFFREY MARK (DDS)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MARK
Last Name:PHILLIP
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 1:224 42 64TH AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:OAKLAND GARDENS
Mailing Address - State:NY
Mailing Address - Zip Code:11364
Mailing Address - Country:US
Mailing Address - Phone:718-225-3103
Mailing Address - Fax:
Practice Address - Street 1:22442 64TH AVE
Practice Address - Street 2:SUITE B
Practice Address - City:OAKLAND GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11364-2327
Practice Address - Country:US
Practice Address - Phone:718-225-3103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-30
Last Update Date:2008-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY037845122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist