Provider Demographics
NPI:1073658753
Name:BLUE DIAMOND DENTAL PA
Entity Type:Organization
Organization Name:BLUE DIAMOND DENTAL PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:302-655-8387
Mailing Address - Street 1:2300 PENNSYLVANIA AVE
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19806-1392
Mailing Address - Country:US
Mailing Address - Phone:302-655-8387
Mailing Address - Fax:302-654-7162
Practice Address - Street 1:2300 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 2C
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19806-1392
Practice Address - Country:US
Practice Address - Phone:302-655-8387
Practice Address - Fax:302-654-7162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000021630Medicaid