Provider Demographics
NPI:1417048976
Name:PHILLIPS, ELTANLIA (DDS)
Entity Type:Individual
Prefix:DR
First Name:ELTANLIA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 LOWER FAYETTEVILLE RD
Mailing Address - Street 2:SUITE F
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-6507
Mailing Address - Country:US
Mailing Address - Phone:770-253-7800
Mailing Address - Fax:770-253-7644
Practice Address - Street 1:1201 LOWER FAYETTEVILLE RD
Practice Address - Street 2:SUITE F
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-6509
Practice Address - Country:US
Practice Address - Phone:770-253-7800
Practice Address - Fax:770-253-7644
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0124681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA807838815BMedicaid