Provider Demographics
NPI:1518116946
Name:PHELPS, JOHN T (DMD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:T
Last Name:PHELPS
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 1:205 WALESKA ROAD
Mailing Address - Street 2:SUITE 2-A
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30114
Mailing Address - Country:US
Mailing Address - Phone:770-479-3713
Mailing Address - Fax:770-479-4031
Practice Address - Street 1:205 WALESKA ROAD
Practice Address - Street 2:SUITE 2-A
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30114
Practice Address - Country:US
Practice Address - Phone:770-479-3713
Practice Address - Fax:770-479-4031
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12364122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist