Provider Demographics
NPI:1073409041
Name:PHILLIPS, WILLIAM
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2329 N CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-2023
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:607 W ORCHARD ST
Practice Address - Street 2:
Practice Address - City:VANDALIA
Practice Address - State:IL
Practice Address - Zip Code:62471-1234
Practice Address - Country:US
Practice Address - Phone:618-283-2929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019036160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist