Provider Demographics
NPI:1720179559
Name:POWELL, PHILLIP PRYSE (DDS)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:PRYSE
Last Name:POWELL
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 1:603 RIVERVIEW DR
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:WV
Mailing Address - Zip Code:26134-9718
Mailing Address - Country:US
Mailing Address - Phone:304-665-7813
Mailing Address - Fax:
Practice Address - Street 1:603 RIVERVIEW DR
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:WV
Practice Address - Zip Code:26134-9718
Practice Address - Country:US
Practice Address - Phone:304-665-7813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV31611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0133913000Medicaid