Provider Demographics
NPI:1679642797
Name:PHILLIPS, JAMES T JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:T
Last Name:PHILLIPS
Suffix:JR
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:PO BOX 1295
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-1295
Mailing Address - Country:US
Mailing Address - Phone:229-382-0467
Mailing Address - Fax:229-382-8714
Practice Address - Street 1:209 24TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3170
Practice Address - Country:US
Practice Address - Phone:229-382-0467
Practice Address - Fax:229-382-8714
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2008-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADNO112601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA724756Other724756
GA910231OtherBCBS
GA9184127Medicaid
GA00622421Medicaid
GA101598Medicaid