Healthcare Provider Details

I. General information

NPI: 1033249289
Provider Name (Legal Business Name): DEERWOOD ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 N BALLARD RD
APPLETON WI
54911-8707
US

IV. Provider business mailing address

3030 N BALLARD RD
APPLETON WI
54911-8707
US

V. Phone/Fax

Practice location:
  • Phone: 920-954-9153
  • Fax: 920-954-9080
Mailing address:
  • Phone: 920-954-9153
  • Fax: 920-954-9080

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CELIA HAYES
Title or Position: CREDENTIALING COORDINATOR
Credential:
Phone: 217-540-2100