MEDICARE: PHILLIP D. GOULD, DMD, LLC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1720617137
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PHILLIP D. GOULD, DMD, LLC

Provider Business Mailing Address
First Line	:	15 WIUKA AVE
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29607-3117
Country	:	US
Telephone Number	:	803-360-0982
Fax Number	:

Provider Business Practice Location Address
First Line	:	127 HUNTS BRIDGE RD
Second Line	:
City	:	GREENVILLE
State	:	SC
Zip	:	29617-1623
Country	:	US
Telephone Number	:	864-246-6471
Fax Number	:

Authorized Official
Title or Position	:	GENERAL DENTIST/ OWNER
Name	:	DR. PHILLIP DAVID GOULD
Credential	:	DMD
Telephone Number	:	864-360-0982

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	06/08/2020

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