MEDICARE: DR. PHILLIPS MODERN DENTISTRY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1972958171
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. PHILLIPS MODERN DENTISTRY, PA

Provider Business Mailing Address
First Line	:	PO BOX 920050
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75392-0050
Country	:	US
Telephone Number	:	714-845-8890
Fax Number	:	949-474-1495

Provider Business Practice Location Address
First Line	:	8015 TURKEY LAKE RD
Second Line	:	300
City	:	ORLANDO
State	:	FL
Zip	:	32819-7383
Country	:	US
Telephone Number	:	407-205-0246
Fax Number	:	407-641-4041

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	DR. MINH B PHAM
Credential	:	DDS
Telephone Number	:	407-205-0246

Provider Enumeration Date	:	04/26/2016
Last Update Date	:	08/25/2022

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