Provider Demographics
NPI:1922168616
Name:PHILLIPS, PAUL DAVID (DDS)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:DAVID
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:PO BOX 71
Mailing Address - Street 2:29 NESPELEM SANPOIL STREET
Mailing Address - City:NESPELEM
Mailing Address - State:WA
Mailing Address - Zip Code:99155-0071
Mailing Address - Country:US
Mailing Address - Phone:509-634-2900
Mailing Address - Fax:509-634-2990
Practice Address - Street 1:29 NESPELEM SANPOIL STREET
Practice Address - Street 2:
Practice Address - City:NESPELEM
Practice Address - State:WA
Practice Address - Zip Code:99155-0071
Practice Address - Country:US
Practice Address - Phone:509-634-2900
Practice Address - Fax:509-634-2990
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000054741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5400189Medicaid
WA5400197Medicaid