Provider Demographics
NPI:1104999796
Name:PHILLIPS ORTHODONTICS
Entity type:Organization
Organization Name:PHILLIPS ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHODONTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS, MS
Authorized Official - Phone:608-271-9293
Mailing Address - Street 1:5605 ODANA RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1207
Mailing Address - Country:US
Mailing Address - Phone:608-271-9293
Mailing Address - Fax:608-204-9216
Practice Address - Street 1:5605 ODANA RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1207
Practice Address - Country:US
Practice Address - Phone:608-271-9293
Practice Address - Fax:608-204-9216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-15
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI46031223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33722200Medicaid