Healthcare Provider Details

I. General information

NPI: 1245229202
Provider Name (Legal Business Name): WILLIAM A PHILLIPS DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 DUPONT SQ N
LOUISVILLE KY
40207-4612
US

IV. Provider business mailing address

1001 DUPONT SQ N
LOUISVILLE KY
40207-4612
US

V. Phone/Fax

Practice location:
  • Phone: 502-897-0625
  • Fax: 502-897-0627
Mailing address:
  • Phone: 502-897-0625
  • Fax: 502-897-0627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number04017
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number04017
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: