Provider Demographics
NPI:1033469036
Name:PHELPS, JOHN SPENCER (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SPENCER
Last Name:PHELPS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 STONE LAKE DRIVE
Mailing Address - Street 2:
Mailing Address - City:MAKANDA
Mailing Address - State:IL
Mailing Address - Zip Code:62958-2730
Mailing Address - Country:US
Mailing Address - Phone:618-549-4550
Mailing Address - Fax:
Practice Address - Street 1:180 STONE LAKE DR
Practice Address - Street 2:
Practice Address - City:MAKANDA
Practice Address - State:IL
Practice Address - Zip Code:62958-2730
Practice Address - Country:US
Practice Address - Phone:618-549-4550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL019014490122300000X
IL0210008261223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics