Provider Demographics
NPI: | 1508988585 |
---|---|
Name: | PHELAN ORTHODONTICS, PA |
Entity Type: | Organization |
Organization Name: | PHELAN ORTHODONTICS, PA |
Other - Org Name: | PHELAN ORTHODONTICS |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | RICHARD |
Authorized Official - Middle Name: | T |
Authorized Official - Last Name: | PHELAN |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS, MS |
Authorized Official - Phone: | 501-224-6535 |
Mailing Address - Street 1: | 1801 RAHLING RD STE 101 |
Mailing Address - Street 2: | |
Mailing Address - City: | LITTLE ROCK |
Mailing Address - State: | AR |
Mailing Address - Zip Code: | 72223-4777 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 501-224-6535 |
Mailing Address - Fax: | 501-224-8652 |
Practice Address - Street 1: | 1801 RAHLING RD STE 101 |
Practice Address - Street 2: | |
Practice Address - City: | LITTLE ROCK |
Practice Address - State: | AR |
Practice Address - Zip Code: | 72223-4777 |
Practice Address - Country: | US |
Practice Address - Phone: | 501-224-6535 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-04-03 |
Last Update Date: | 2021-01-04 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223X0400X | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | Group - Single Specialty |