Healthcare Provider Details

I. General information

NPI: 1659347268
Provider Name (Legal Business Name): THADDEUS HILLIARD PHILLIPS III D.M.D./M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

51 MEDICAL GROUP/ DENTAL SQUADRON
APO AP
96278-2060
KR

IV. Provider business mailing address

PSC #3 BOX 128
APO AP
96266-0001
KR

V. Phone/Fax

Practice location:
  • Phone: 011943157842108
  • Fax:
Mailing address:
  • Phone: 011943157842108
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number045133-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: