Provider Demographics
NPI:1326603044
Name:MID- ATLANTIC DENTAL PARTNERS DELAWARE III, PA
Entity Type:Organization
Organization Name:MID- ATLANTIC DENTAL PARTNERS DELAWARE III, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LORRAINE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALLEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:484-455-4550
Mailing Address - Street 1:4133 OGLETOWN STANTON RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-4168
Mailing Address - Country:US
Mailing Address - Phone:484-455-4550
Mailing Address - Fax:484-284-5102
Practice Address - Street 1:4133 OGLETOWN STANTON RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4168
Practice Address - Country:US
Practice Address - Phone:484-455-4550
Practice Address - Fax:484-284-5102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-08
Last Update Date:2019-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental