Provider Demographics
NPI:1790996171
Name:PHILLIPS, JOHN QUAIL JR (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:QUAIL
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 1:204 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ZELIENOPLE
Mailing Address - State:PA
Mailing Address - Zip Code:16063-2306
Mailing Address - Country:US
Mailing Address - Phone:724-452-9732
Mailing Address - Fax:724-453-5022
Practice Address - Street 1:204 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ZELIENOPLE
Practice Address - State:PA
Practice Address - Zip Code:16063-2306
Practice Address - Country:US
Practice Address - Phone:724-452-9732
Practice Address - Fax:724-453-5022
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS017888L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist