Provider Demographics
NPI:1619102811
Name:DOVER ORAL AND MAXILLOFACIAL SURGERY
Entity Type:Organization
Organization Name:DOVER ORAL AND MAXILLOFACIAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORAL AND MAXILLOFACIAL SURGEON
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANKLIN
Authorized Official - Middle Name:XAVIER
Authorized Official - Last Name:PANCKO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:443-939-0942
Mailing Address - Street 1:3450 WAYNE AVE APT 28M
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2554
Mailing Address - Country:US
Mailing Address - Phone:443-939-0942
Mailing Address - Fax:
Practice Address - Street 1:712 S GOVERNORS AVE
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-4106
Practice Address - Country:US
Practice Address - Phone:302-674-1140
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-18
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00012691223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty