Provider Demographics
NPI: | 1598837361 |
---|---|
Name: | STATE OF DELAWARE |
Entity Type: | Organization |
Organization Name: | STATE OF DELAWARE |
Other - Org Name: | MILFORD DENTAL |
Other - Org Type: | Other Name |
Authorized Official - Title/Position: | DENTAL DIRECTOR |
Authorized Official - Prefix: | |
Authorized Official - First Name: | GREGORY |
Authorized Official - Middle Name: | B |
Authorized Official - Last Name: | MCCLURE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DMD |
Authorized Official - Phone: | 302-744-4554 |
Mailing Address - Street 1: | 417 FEDERAL ST |
Mailing Address - Street 2: | |
Mailing Address - City: | DOVER |
Mailing Address - State: | DE |
Mailing Address - Zip Code: | 19901-3635 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 302-744-4548 |
Mailing Address - Fax: | 302-739-1613 |
Practice Address - Street 1: | 417 FEDERAL ST |
Practice Address - Street 2: | |
Practice Address - City: | DOVER |
Practice Address - State: | DE |
Practice Address - Zip Code: | 19901-3635 |
Practice Address - Country: | US |
Practice Address - Phone: | 302-744-4548 |
Practice Address - Fax: | 302-739-1613 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-11-15 |
Last Update Date: | 2011-12-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QD0000X | Ambulatory Health Care Facilities | Clinic/Center | Dental |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
DE | 0000087548 | Medicaid |