Healthcare Provider Details

I. General information

NPI: 1912920745
Provider Name (Legal Business Name): CHARLES CLAYTON PHILLIPS III D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHARLES PHILLIPS III

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12395 EL CAMINO REAL STE 304
SAN DIEGO CA
92130-3085
US

IV. Provider business mailing address

12395 EL CAMINO REAL STE 304
SAN DIEGO CA
92130-3085
US

V. Phone/Fax

Practice location:
  • Phone: 858-793-3393
  • Fax: 858-793-3383
Mailing address:
  • Phone: 858-793-3393
  • Fax: 858-793-3383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number30008
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: