Basic Information
Provider Information | |||||||||
NPI: | 1760041248 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PHILLIPS | ||||||||
FirstName: | BRIANNA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DDS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DAVIDSON | ||||||||
OtherFirstName: | BRIANNA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DDS | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 3004 SW HAZELNUT AVE | ||||||||
Address2: |   | ||||||||
City: | BENTONVILLE | ||||||||
State: | AR | ||||||||
PostalCode: | 72713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4174389133 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 927 N 71 BUSINESS HWY | ||||||||
Address2: |   | ||||||||
City: | ANDERSON | ||||||||
State: | MO | ||||||||
PostalCode: | 648319753 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4178452273 | ||||||||
FaxNumber: | 4178450094 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/10/2019 | ||||||||
LastUpdateDate: | 06/10/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | 2019019148 | MO | Y |   | Dental Providers | Dentist |   |
No ID Information.