Provider Demographics
NPI:1760041248
Name:PHILLIPS, BRIANNA L (DDS)
Entity type:Individual
Prefix:
First Name:BRIANNA
Middle Name:L
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:BRIANNA
Other - Middle Name:L
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:3004 SW HAZELNUT AVE
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72713
Mailing Address - Country:US
Mailing Address - Phone:417-438-9133
Mailing Address - Fax:
Practice Address - Street 1:1607 E RAINFOREST RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-5385
Practice Address - Country:US
Practice Address - Phone:479-582-0600
Practice Address - Fax:417-845-0094
Is Sole Proprietor?:No
Enumeration Date:2019-06-10
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019019148122300000X
AR43821223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist