Provider Demographics
NPI:1780817072
Name:LANCE, PHILLIP OLIVER (DDS)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:OLIVER
Last Name:LANCE
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:BLDG 2441 21ST STREET
Mailing Address - Street 2:U S ARMY DENTAC
Mailing Address - City:FORT CAMPBELL
Mailing Address - State:KY
Mailing Address - Zip Code:42223-5369
Mailing Address - Country:US
Mailing Address - Phone:270-798-8614
Mailing Address - Fax:270-798-8633
Practice Address - Street 1:BLDG 2441 21ST STREET
Practice Address - Street 2:U S ARMY DENTAC
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5369
Practice Address - Country:US
Practice Address - Phone:270-798-8614
Practice Address - Fax:270-798-8633
Is Sole Proprietor?:No
Enumeration Date:2009-09-02
Last Update Date:2009-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.023052122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist