Provider Demographics
NPI:1669120259
Name:DEERWOOD ORTHODONTICS, LLC
Entity type:Organization
Organization Name:DEERWOOD ORTHODONTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:500 W SILVER SPRING DR STE K230
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5053
Mailing Address - Country:US
Mailing Address - Phone:414-332-4900
Mailing Address - Fax:414-332-4949
Practice Address - Street 1:500 W SILVER SPRING DR STE K230
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5053
Practice Address - Country:US
Practice Address - Phone:414-332-4900
Practice Address - Fax:414-332-4949
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEERWOOD ORTHODONTICS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty