Healthcare Provider Details

I. General information

NPI: 1952381899
Provider Name (Legal Business Name): NATHAN ALEXANDER PHILLIPS DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 08/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 OAK TREE LN
DAKOTA DUNES SD
57049
US

IV. Provider business mailing address

301 OAK TREE LN
DAKOTA DUNES SD
57049-5095
US

V. Phone/Fax

Practice location:
  • Phone: 605-242-0107
  • Fax: 605-242-0145
Mailing address:
  • Phone: 605-242-0107
  • Fax: 605-242-0145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number09366
License Number StateIA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberD1140
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: