=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720118987
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEERWOOD ORTHODONTICS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 03/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | N80W17707 CUSTER LN
-----------------------------------------------------
City | MENOMONEE FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53051-3630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-502-0605
-----------------------------------------------------
Fax | 262-415-1266
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | N80W17707 CUSTER LN
-----------------------------------------------------
City | MENOMONEE FALLS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53051-3630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-502-0605
-----------------------------------------------------
Fax | 262-415-1266
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CREDENTIALING COORDINATOR
-----------------------------------------------------
Name | CELIA HAYES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 217-540-2100
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------