Provider Demographics
NPI:1346356680
Name:GILMER, PHILLIP WESLEY (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WESLEY
Last Name:GILMER
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 1:208 PARKWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTON
Mailing Address - State:TN
Mailing Address - Zip Code:37643-2845
Mailing Address - Country:US
Mailing Address - Phone:423-543-5200
Mailing Address - Fax:423-543-1499
Practice Address - Street 1:208 PARKWAY BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETHTON
Practice Address - State:TN
Practice Address - Zip Code:37643-2845
Practice Address - Country:US
Practice Address - Phone:423-543-5200
Practice Address - Fax:423-543-1499
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDS24461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0005594Medicaid