Provider Demographics
NPI:1447378526
Name:STELLY, PHILLIP LYLE (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:LYLE
Last Name:STELLY
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 1:258 ARCENEAUX RD
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520
Mailing Address - Country:US
Mailing Address - Phone:337-896-3267
Mailing Address - Fax:337-896-7852
Practice Address - Street 1:258 ARCENEAUX RD
Practice Address - Street 2:
Practice Address - City:CARENCRO
Practice Address - State:LA
Practice Address - Zip Code:70520
Practice Address - Country:US
Practice Address - Phone:337-896-3267
Practice Address - Fax:337-896-7852
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4453122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1844535Medicaid