1477556470 NPI number — DR. PHYLLIS HORNING DETWILER DMD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477556470 NPI number — DR. PHYLLIS HORNING DETWILER DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETWILER
Provider First Name:
PHYLLIS
Provider Middle Name:
HORNING
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477556470
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
113 N BREAD ST
Provider Second Line Business Mailing Address:
APARTMENT 2B
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19106-4610
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
732-567-6333
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
110 MARTER AVE
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
MOORESTOWN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08057-3124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-727-6453
Provider Business Practice Location Address Fax Number:
856-727-4039
Provider Enumeration Date:
05/23/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  22DI01130400 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 22DI011130400 . This is a "DENTAL LICENSE" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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