MEDICARE: DR. JOHN PHILLIP IREY DDS

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
1	122300000X	Dentist	1001038-15	WI
2	122300000X	Dentist	8088	MD
3	1223G0001X	General Practice Dentistry	DD5248	NM
4	1223G0001X	General Practice Dentistry	1001038-15	WI

General Provider Information

NPI Number	:	1578660213
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN PHILLIP IREY DDS

Provider Business Mailing Address
First Line	:	PO BOX 158
Second Line	:
City	:	CHESAPEAKE BEACH
State	:	MD
Zip	:	20732-0158
Country	:	US
Telephone Number	:	301-481-6664
Fax Number	:

Provider Business Practice Location Address
First Line	:	4010 S CHURCH DR
Second Line	:
City	:	NEW BERLIN
State	:	WI
Zip	:	53151-5608
Country	:	US
Telephone Number	:	262-784-2449
Fax Number	:	262-784-7873

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/17/2006
Last Update Date	:	08/23/2022

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