=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447650809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | E KEITH PHILLIPS DDS
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/03/2014
-----------------------------------------------------
Last Update Date | 09/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10405 MONTGOMERY AVE
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-219-0451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10405 MONTGOMERY AVE
-----------------------------------------------------
City | KENSINGTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20895-3357
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-219-0451
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. ELLERY KEITH PHILLIPS
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 301-219-0451
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332BP3500X
-----------------------------------------------------
Taxonomy Name | Parenteral & Enteral Nutrition Supplies (DME)
-----------------------------------------------------
License Number | 4705
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------