Provider Demographics
NPI:1699094151
Name:PHILIPS, BROCK (DMD)
Entity type:Individual
Prefix:DR
First Name:BROCK
Middle Name:
Last Name:PHILIPS
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 SOUTHSIDE BLVD
Mailing Address - Street 2:SUITE 801
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-5492
Mailing Address - Country:US
Mailing Address - Phone:904-642-2010
Mailing Address - Fax:904-642-8282
Practice Address - Street 1:4540 SOUTHSIDE BLVD
Practice Address - Street 2:SUITE 801
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-5492
Practice Address - Country:US
Practice Address - Phone:904-642-2010
Practice Address - Fax:904-642-8282
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-24
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN143541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice