Provider Demographics
NPI:1538201991
Name:PHILLIPS, RICHARD JOHN JR (DMD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOHN
Last Name:PHILLIPS
Suffix:JR
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 1:1768 RUSSET LANE
Mailing Address - Street 2:
Mailing Address - City:SAN MARINO
Mailing Address - State:CA
Mailing Address - Zip Code:91108-3022
Mailing Address - Country:US
Mailing Address - Phone:626-285-9206
Mailing Address - Fax:
Practice Address - Street 1:632 SOUTH EREMLAND DR
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91743-3523
Practice Address - Country:US
Practice Address - Phone:626-339-5891
Practice Address - Fax:626-339-5027
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30687122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist