Provider Demographics
NPI:1245492891
Name:COPENHAVER, PHILIP A (DDS)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
Last Name:COPENHAVER
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 1:10230 FORD AVENUE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:GA
Mailing Address - Zip Code:31324
Mailing Address - Country:US
Mailing Address - Phone:912-756-2936
Mailing Address - Fax:912-756-2931
Practice Address - Street 1:10230 FORD AVENUE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:GA
Practice Address - Zip Code:31324
Practice Address - Country:US
Practice Address - Phone:912-756-2936
Practice Address - Fax:912-756-2931
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0122351223G0001X
GADNO122351223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice