John Spencer Phelps, DDS
Individual provider Active NPI Dentist · Makanda, IL
NPI 1033469036 · NPPES record last updated Sep 17, 2012
Key facts
- NPI
- 1033469036
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Dentist 122300000X
- License
- 019014490 (IL)
- Practice address
- 180 Stone Lake Dr
Makanda, IL 62958-2730 - Phone
- (618) 549-4550
- NPI assigned
- Sep 17, 2012
- Sex
- Male
- Sole proprietor
- Yes
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 019014490 | IL | MD | Dentist |
| 021000826 | IL | MD | Orthodontics and Dentofacial Orthopedic Dentist |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Dentist | 122300000X | 019014490 | IL | Yes |
| Orthodontics and Dentofacial Orthopedics Dentistry | 1223X0400X | 021000826 | IL |
Addresses
Primary practice location
180 Stone Lake Dr
Makanda, IL 62958-2730
Mailing address
180 Stone Lake Drive
Makanda, IL 62958-2730
Phone (618) 549-4550
Other providers in Makanda, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Sep 17, 2012. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.