Healthcare Provider Details

I. General information

NPI: 1790842672
Provider Name (Legal Business Name): HENRY PHILLIPS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 01/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 N WESTERN AVE SUITE # 205
LOS ANGELES CA
90029-1088
US

IV. Provider business mailing address

4712 ADMIRALTY WAY # 461
MARINA DEL REY CA
90292-6905
US

V. Phone/Fax

Practice location:
  • Phone: 323-476-2114
  • Fax:
Mailing address:
  • Phone: 310-733-7150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number49394
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: