Provider Demographics
NPI:1114057825
Name:DENTAL HEALTH CENTER OF DEL-TECH
Entity Type:Organization
Organization Name:DENTAL HEALTH CENTER OF DEL-TECH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL HEALTH CENTER MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAMEKA
Authorized Official - Middle Name:D
Authorized Official - Last Name:REEVES-RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:CDA
Authorized Official - Phone:302-657-5176
Mailing Address - Street 1:333 N SHIPLEY ST
Mailing Address - Street 2:THE DENTAL HEALTH CENTER
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19801-2412
Mailing Address - Country:US
Mailing Address - Phone:302-657-5176
Mailing Address - Fax:302-657-5127
Practice Address - Street 1:333 N SHIPLEY ST
Practice Address - Street 2:THE DENTAL HEALTH CENTER
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19801-2412
Practice Address - Country:US
Practice Address - Phone:302-657-5176
Practice Address - Fax:302-657-5127
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000198748Medicaid
DE=========OtherTIN#