Healthcare Provider Details

I. General information

NPI: 1659460772
Provider Name (Legal Business Name): WILLIAM JONES PHILLIPS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 04/23/2020
Certification Date: 04/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 MEDICAL PARK LANE
GAINESVILLE GA
30501
US

IV. Provider business mailing address

698 MEDICAL PARK LANE
GAINESVILLE GA
30501
US

V. Phone/Fax

Practice location:
  • Phone: 770-718-1090
  • Fax: 770-718-0198
Mailing address:
  • Phone: 770-718-1090
  • Fax: 770-718-0198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN9961
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberDN009961
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: