=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548431166
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | B. ERIC PHILLIPS D.M.D., P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2008
-----------------------------------------------------
Last Update Date | 03/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 103 MARK DR
-----------------------------------------------------
City | EDENTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27932-1704
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-540-2235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 911
-----------------------------------------------------
City | EDENTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27932-0911
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | BYRON ERIC PHILLIPS
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 302-540-2235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 8512
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------