Provider Demographics
NPI:1790842672
Name:PHILLIPS, HENRY (DDS)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:
Last Name:PHILLIPS
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 1:4712 ADMIRALTY WAY # 461
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6905
Mailing Address - Country:US
Mailing Address - Phone:310-733-7150
Mailing Address - Fax:
Practice Address - Street 1:1110 N WESTERN AVE
Practice Address - Street 2:SUITE # 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1088
Practice Address - Country:US
Practice Address - Phone:323-476-2114
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49394122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD49394Medicaid