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NPI Code Detail

MEDICARE: DR. PHYLLIS HORNING DETWILER DMD

MEDICARE: DR. PHYLLIS HORNING DETWILER DMD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11223G0001XGeneral Practice Dentistry22DI01130400NJ

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
122DI011130400OTHERNJDENTAL LICENSE

General Provider Information

NPI Number : 1477556470
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. PHYLLIS HORNING DETWILER DMD
Provider Business Mailing Address
First Line : 113 N BREAD ST
Second Line : APARTMENT 2B
City : PHILADELPHIA
State : PA
Zip : 19106-4610
Country : US
Telephone Number : 732-567-6333
Fax Number :
Provider Business Practice Location Address
First Line : 110 MARTER AVE
Second Line : SUITE 204
City : MOORESTOWN
State : NJ
Zip : 08057-3124
Country : US
Telephone Number : 856-727-6453
Fax Number : 856-727-4039
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2005
Last Update Date : 01/03/2015

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