Provider Demographics
NPI:1245721356
Name:TIMOTHY M PHILLIPS DDS INC
Entity type:Organization
Organization Name:TIMOTHY M PHILLIPS DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:330-948-1243
Mailing Address - Street 1:115 BANK ST
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:OH
Mailing Address - Zip Code:44254-1001
Mailing Address - Country:US
Mailing Address - Phone:330-948-1243
Mailing Address - Fax:330-948-4706
Practice Address - Street 1:115 BANK ST
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:OH
Practice Address - Zip Code:44254-1001
Practice Address - Country:US
Practice Address - Phone:330-948-1243
Practice Address - Fax:330-948-4706
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.025077122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0220616Medicaid