Healthcare Provider Details

I. General information

NPI: 1710491725
Provider Name (Legal Business Name): AMY PHILLIPS DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2017
Last Update Date: 11/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 E WESTFIELD AVE
ROSELLE PARK NJ
07204-2283
US

IV. Provider business mailing address

14 E WESTFIELD AVE
ROSELLE PARK NJ
07204-2283
US

V. Phone/Fax

Practice location:
  • Phone: 908-245-7700
  • Fax: 908-245-7791
Mailing address:
  • Phone: 908-245-7700
  • Fax: 908-245-7791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number22DI02516800
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number22DI01322901
License Number StateNJ

VIII. Authorized Official

Name: DR. AMY PHILLIPS
Title or Position: PEDIATRIC DENTIST
Credential: DMD
Phone: 908-403-3492