Provider Demographics
NPI:1184812091
Name:PHILLIPS, JUSTIN D (DDS)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:D
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 1:2655 CLEVELAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2779
Mailing Address - Country:US
Mailing Address - Phone:707-542-1026
Mailing Address - Fax:707-542-1058
Practice Address - Street 1:2655 CLEVELAND AVE STE B
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2779
Practice Address - Country:US
Practice Address - Phone:707-542-1026
Practice Address - Fax:707-542-1058
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA438451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice