Provider Demographics
NPI: | 1508991043 |
---|---|
Name: | YOUR DENTISTRY TODAY |
Entity Type: | Organization |
Organization Name: | YOUR DENTISTRY TODAY |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | MICHAEL |
Authorized Official - Middle Name: | D |
Authorized Official - Last Name: | MATTHIAS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 302-575-0100 |
Mailing Address - Street 1: | 3844 KENNETT PIKE STE 206 |
Mailing Address - Street 2: | |
Mailing Address - City: | GREENVILLE |
Mailing Address - State: | DE |
Mailing Address - Zip Code: | 19807-2305 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 302-575-0100 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 3844 KENNETT PIKE |
Practice Address - Street 2: | SUITE 206 |
Practice Address - City: | GREENVILLE |
Practice Address - State: | DE |
Practice Address - Zip Code: | 19807-2305 |
Practice Address - Country: | US |
Practice Address - Phone: | 302-575-0100 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-02-23 |
Last Update Date: | 2009-08-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
DE | 0001158408 | Medicaid |