Healthcare Provider Details

I. General information

NPI: 1700534294
Provider Name (Legal Business Name): DEERWOOD ORTHODONTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

1532 S GREEN BAY RD STE 100
MOUNT PLEASANT WI
53406-4468
US

IV. Provider business mailing address

1532 S GREEN BAY RD STE 100
MOUNT PLEASANT WI
53406-4468
US

V. Phone/Fax

Practice location:
  • Phone: 262-632-3300
  • Fax:
Mailing address:
  • Phone: 262-632-3300
  • Fax:

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