Provider Demographics
NPI:1922167410
Name:PHILLIPS, KELLY JO (DDS)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:JO
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 MCMILLAN ST.
Mailing Address - Street 2:PO BOX 727
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187
Mailing Address - Country:US
Mailing Address - Phone:507-376-5525
Mailing Address - Fax:
Practice Address - Street 1:1316 MCMILLAN ST
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-1646
Practice Address - Country:US
Practice Address - Phone:507-376-5525
Practice Address - Fax:507-376-3796
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND121931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN687623400Medicaid