MEDICARE: DEERWOOD ORTHODONTICS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry

General Provider Information

NPI Number	:	1760130264
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DEERWOOD ORTHODONTICS, LLC

Provider Business Mailing Address
First Line	:	100 WILBURN RD STE 203
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1478
Country	:	US
Telephone Number	:	608-837-7901
Fax Number	:

Provider Business Practice Location Address
First Line	:	100 WILBURN RD STE 203
Second Line	:
City	:	SUN PRAIRIE
State	:	WI
Zip	:	53590-1478
Country	:	US
Telephone Number	:	608-837-7901
Fax Number	:

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	CELIA HAYES
Credential	:
Telephone Number	:	217-540-2100

Provider Enumeration Date	:	03/14/2022
Last Update Date	:	03/14/2022

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