Healthcare Provider Details

I. General information

NPI: 1053434498
Provider Name (Legal Business Name): BRADLEY L PHILLIPS D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 ROCK SPRING RD
FOREST HILL MD
21050-2631
US

IV. Provider business mailing address

15927 YORK RD
SPARKS MD
21152-9343
US

V. Phone/Fax

Practice location:
  • Phone: 410-879-4444
  • Fax: 410-893-0112
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number8121
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: