Healthcare Provider Details

I. General information

NPI: 1720064678
Provider Name (Legal Business Name): ROBERT C PHILLIPS JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 MAIN ST
PINEVILLE NC
28134-7322
US

IV. Provider business mailing address

PO BOX 686
PINEVILLE NC
28134-0686
US

V. Phone/Fax

Practice location:
  • Phone: 704-889-7525
  • Fax: 704-889-7528
Mailing address:
  • Phone: 704-889-7525
  • Fax: 704-889-7528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number3390
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: