Provider Demographics
NPI:1174698492
Name:ABBOTT, PHILLIP EDWARD (DDS)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:EDWARD
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 EAST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:BARTOW
Mailing Address - State:FL
Mailing Address - Zip Code:33830
Mailing Address - Country:US
Mailing Address - Phone:863-533-9471
Mailing Address - Fax:863-519-6481
Practice Address - Street 1:780 EAST MAIN STREET
Practice Address - Street 2:
Practice Address - City:BARTOW
Practice Address - State:FL
Practice Address - Zip Code:33830
Practice Address - Country:US
Practice Address - Phone:863-533-9471
Practice Address - Fax:863-519-6481
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL09526122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist