Healthcare Provider Details

I. General information

NPI: 1578244265
Provider Name (Legal Business Name): EMILY PHELAN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2023
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3740 SOUTH 14TH STREET
JOINT BASE LEWIS MCCHORD WA
98431-0001
US

IV. Provider business mailing address

9900 LINCOLN STREET 2ND FLOOR
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-967-5271
  • Fax:
Mailing address:
  • Phone: 253-968-4079
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number13461648-9921
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: