=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346771904
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALEXIS PHILLIPS D.M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/24/2017
-----------------------------------------------------
Last Update Date | 03/19/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 E MALLARD DR
-----------------------------------------------------
City | BOISE
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83706-3975
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-500-5437
-----------------------------------------------------
Fax | 208-908-6178
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 NATIONAL DR
-----------------------------------------------------
City | JOHNS CREEK
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30097-2079
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-856-1308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number | D-5002-PD
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------