Provider Demographics
NPI:1831616358
Name:PHILLIPS, DONOVAN HUSTON (DMD)
Entity type:Individual
Prefix:
First Name:DONOVAN
Middle Name:HUSTON
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2550 SANDY PLAINS RD STE 145
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30066-7221
Mailing Address - Country:US
Mailing Address - Phone:770-321-2755
Mailing Address - Fax:
Practice Address - Street 1:2550 SANDY PLAINS RD STE 145
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30066-7221
Practice Address - Country:US
Practice Address - Phone:770-321-2755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0155211223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice