Provider Demographics
NPI:1346264520
Name:PHOENIX, DAVID WALTER (DMD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:WALTER
Last Name:PHOENIX
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 1:15 LAWRENCE RD
Mailing Address - Street 2:
Mailing Address - City:BOXFORD
Mailing Address - State:MA
Mailing Address - Zip Code:01921-2205
Mailing Address - Country:US
Mailing Address - Phone:978-887-6373
Mailing Address - Fax:978-887-0844
Practice Address - Street 1:15 LAWRENCE RD
Practice Address - Street 2:
Practice Address - City:BOXFORD
Practice Address - State:MA
Practice Address - Zip Code:01921-2205
Practice Address - Country:US
Practice Address - Phone:978-887-6373
Practice Address - Fax:978-887-0844
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA188191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice