Provider Demographics
NPI:1851517825
Name:PHYLLIS H. DETWILER DMD PC
Entity Type:Organization
Organization Name:PHYLLIS H. DETWILER DMD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:HORNING
Authorized Official - Last Name:DETWILER
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:732-345-8460
Mailing Address - Street 1:429 STATE ROUTE 35
Mailing Address - Street 2:
Mailing Address - City:RED BANK
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-5914
Mailing Address - Country:US
Mailing Address - Phone:732-345-8460
Mailing Address - Fax:
Practice Address - Street 1:429 STATE ROUTE 35
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-5914
Practice Address - Country:US
Practice Address - Phone:732-345-8460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI011304122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty