Healthcare Provider Details

I. General information

NPI: 1104999796
Provider Name (Legal Business Name): PHILLIPS ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 12/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5605 ODANA RD
MADISON WI
53719-1207
US

IV. Provider business mailing address

5605 ODANA RD
MADISON WI
53719-1207
US

V. Phone/Fax

Practice location:
  • Phone: 608-271-9293
  • Fax: 608-204-9216
Mailing address:
  • Phone: 608-271-9293
  • Fax: 608-204-9216

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number4603
License Number StateWI

VIII. Authorized Official

Name: DR. JEFFREY JOSEPH PHILLIPS
Title or Position: ORTHODONTIST
Credential: D.D.S, M.S.
Phone: 608-271-9293