Provider Demographics
NPI:1760864110
Name:PHILLIPS, BRENDA
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 MDG/SGHJ
Mailing Address - Street 2:4881 SUGAR MAPLE DR.
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-257-8761
Mailing Address - Fax:
Practice Address - Street 1:88 MDG/SGHJ
Practice Address - Street 2:4881 SUGAR MAPLE DR.
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45423
Practice Address - Country:US
Practice Address - Phone:937-257-8761
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH30.0199801223G0001X
OH01-99801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice