Provider Demographics
NPI:1942395538
Name:PHILLIS, CORNELIA ANN MOORE (DDS)
Entity Type:Individual
Prefix:DR
First Name:CORNELIA
Middle Name:ANN MOORE
Last Name:PHILLIS
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 1:2329 S WW WHITE RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78222-1936
Mailing Address - Country:US
Mailing Address - Phone:210-648-2451
Mailing Address - Fax:210-648-4140
Practice Address - Street 1:2329 S WW WHITE RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78222-1936
Practice Address - Country:US
Practice Address - Phone:210-648-2451
Practice Address - Fax:210-648-4140
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX187761223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX159776701Medicaid