Provider Demographics
NPI:1568563088
Name:BRANDYWINE VALLEY ORAL & MAXIOLLOFACIAL SURGERY
Entity Type:Organization
Organization Name:BRANDYWINE VALLEY ORAL & MAXIOLLOFACIAL SURGERY
Other - Org Name:BVOMS
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:D
Authorized Official - Last Name:WHITLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDD
Authorized Official - Phone:717-442-9537
Mailing Address - Street 1:5279 LINCOLN HWY
Mailing Address - Street 2:
Mailing Address - City:GAP
Mailing Address - State:PA
Mailing Address - Zip Code:17527-9427
Mailing Address - Country:US
Mailing Address - Phone:717-442-9537
Mailing Address - Fax:717-442-8311
Practice Address - Street 1:5279 LINCOLN HWY
Practice Address - Street 2:
Practice Address - City:GAP
Practice Address - State:PA
Practice Address - Zip Code:17527-9427
Practice Address - Country:US
Practice Address - Phone:717-442-9537
Practice Address - Fax:717-442-8311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA200631OtherKEYSTONE CENTRAL
PA0132579000OtherKEYSTONE EAST
PA02628400OtherCAPITAL BLUE CROSS