Provider Demographics
NPI:1326077694
Name:PHILLIPPI AND KWON DENTISTRY PARTNERSHIP
Entity Type:Organization
Organization Name:PHILLIPPI AND KWON DENTISTRY PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:PHILLIPPI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:704-509-4513
Mailing Address - Street 1:2770 E WT HARRIS BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28213-4096
Mailing Address - Country:US
Mailing Address - Phone:704-509-4513
Mailing Address - Fax:704-509-4516
Practice Address - Street 1:2770 E WT HARRIS BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28213-4096
Practice Address - Country:US
Practice Address - Phone:704-509-4513
Practice Address - Fax:704-509-4516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC51701223G0001X
NC68381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89014V2Medicaid