Basic Information
| Provider Information | |||||||||
| NPI: | 1407249410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | BLDG 38801 ACADEMIC DR SUITE B&C | ||||||||
| Address2: | USA DENTAC ATTN: CREDENTIALS | ||||||||
| City: | FT GORDON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309055660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7067876927 | ||||||||
| FaxNumber: | 7067872082 | ||||||||
| Practice Location | |||||||||
| Address1: | USA DENTAL HEALTH ACTIVITY | ||||||||
| Address2: | 7061 LINCOLN AVE, BLDG 972 | ||||||||
| City: | FT BENNING | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065443103 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2015 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | DS039957 | PA | N | Dental Providers | Dentist | 1223G0001X | DS039957 | PA | N | Dental Providers | Dentist | General Practice | 1223P0300X | DS039957 | PA | Y | Dental Providers | Dentist | Periodontics |
No ID Information.