MEDICARE: PHILLIP WAYNE HEAD SR. DDS CAGS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223E0200X	Endodontics	DS3913	TN

General Provider Information

NPI Number	:	1154312437
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILLIP WAYNE HEAD SR. DDS CAGS

Provider Business Mailing Address
First Line	:	1324 TROTWOOD AVE
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-4750
Country	:	US
Telephone Number	:	931-388-5627
Fax Number	:	931-381-6797

Provider Business Practice Location Address
First Line	:	1324 TROTWOOD AVE
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-4750
Country	:	US
Telephone Number	:	931-388-5627
Fax Number	:	931-381-6797

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	07/08/2007

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