Healthcare Provider Details

I. General information

NPI: 1467715581
Provider Name (Legal Business Name): BRANDON LEE PHILLIPS D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2012
Last Update Date: 06/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1150 HEALTH SCIENCES CENTER ROBERT C. BYRD HEALTH SCIENCES CENTER
MORGANTOWN WV
26506-9100
US

IV. Provider business mailing address

136 ASHLEY OAKS
MORGANTOWN WV
26505-3652
US

V. Phone/Fax

Practice location:
  • Phone: 304-293-6208
  • Fax:
Mailing address:
  • Phone: 304-237-8241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number4001
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: