Provider Demographics
NPI:1952411019
Name:PHILLIPS, DAVID PAUL (DDS)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:PAUL
Last Name:PHILLIPS
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:PO BOX 10007
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72917
Mailing Address - Country:US
Mailing Address - Phone:479-452-2994
Mailing Address - Fax:479-484-5865
Practice Address - Street 1:1501 S WALDRON RD
Practice Address - Street 2:SUITE 208
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-2574
Practice Address - Country:US
Practice Address - Phone:479-452-2994
Practice Address - Fax:479-484-5865
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2012-08-01
Deactivation Date:2010-03-26
Deactivation Code:
Reactivation Date:2012-05-01
Provider Licenses
StateLicense IDTaxonomies
AR20341223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR184553608Medicaid