Provider Demographics
NPI:1730203696
Name:PHILLIPS, DAVID M (DDS)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:PHILLIPS
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 1:2110 ENTERPRISE ST SE STE 201
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508-5050
Mailing Address - Country:US
Mailing Address - Phone:616-249-9002
Mailing Address - Fax:616-249-0046
Practice Address - Street 1:2110 ENTERPRISE ST SE STE 201
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-5050
Practice Address - Country:US
Practice Address - Phone:616-249-9002
Practice Address - Fax:616-249-0046
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI0148271223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice