Provider Demographics
NPI:1730109794
Name:PHILBRICK, JAMES DAVIDSON JR (DMD,FAGD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:DAVIDSON
Last Name:PHILBRICK
Suffix:JR
Gender:M
Credentials:DMD,FAGD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8449 US HIGHWAY 42
Mailing Address - Street 2:SUITE K
Mailing Address - City:FLORENCE
Mailing Address - State:KY
Mailing Address - Zip Code:41042-8352
Mailing Address - Country:US
Mailing Address - Phone:859-372-6300
Mailing Address - Fax:859-372-6305
Practice Address - Street 1:8449 US HIGHWAY 42
Practice Address - Street 2:SUITE K
Practice Address - City:FLORENCE
Practice Address - State:KY
Practice Address - Zip Code:41042-8352
Practice Address - Country:US
Practice Address - Phone:859-372-6300
Practice Address - Fax:859-372-6305
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY48551223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY56-1660291OtherTAX I.D.
KY4855OtherSTATE LICENSE
KY60048550Medicaid