Provider Demographics
NPI:1144679499
Name:PHILLIPS, WILSON (DMD)
Entity type:Individual
Prefix:DR
First Name:WILSON
Middle Name:
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 1:626 SNYDER AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2419
Mailing Address - Country:US
Mailing Address - Phone:267-940-0300
Mailing Address - Fax:
Practice Address - Street 1:1319 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:PROSPECT PARK
Practice Address - State:PA
Practice Address - Zip Code:19076-1216
Practice Address - Country:US
Practice Address - Phone:610-532-5008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-07
Last Update Date:2018-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PADN002360OtherPA STATE LICENSE NUMBER