Provider Demographics
NPI:1033257530
Name:DITTY, DOUGLAS LYNN (MD, DMD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:LYNN
Last Name:DITTY
Suffix:
Gender:M
Credentials:MD, DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 S STATE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-6925
Mailing Address - Country:US
Mailing Address - Phone:302-674-4450
Mailing Address - Fax:302-678-3228
Practice Address - Street 1:1004 S STATE ST STE 1
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6901
Practice Address - Country:US
Practice Address - Phone:302-674-4450
Practice Address - Fax:302-678-3228
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2019-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEGI-00011931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000039259Medicaid
DE1000039259Medicaid
I47441Medicare UPIN