Provider Demographics
NPI:1386271377
Name:PHILLIP, MEGAN KEIKO (DDS)
Entity type:Individual
Prefix:DR
First Name:MEGAN
Middle Name:KEIKO
Last Name:PHILLIP
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3020 HARTLEY RD STE 210
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32257-8231
Mailing Address - Country:US
Mailing Address - Phone:904-395-7772
Mailing Address - Fax:
Practice Address - Street 1:1319 E OSCEOLA PKWY STE C
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-1606
Practice Address - Country:US
Practice Address - Phone:407-343-0509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-27
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN264171223P0221X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program