Provider Demographics
NPI:1629144589
Name:SOUTHERN DE ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, PA
Entity Type:Organization
Organization Name:SOUTHERN DE ORAL AND MAXILLOFACIAL SURGERY ASSOCIATES, PA
Other - Org Name:BRUCE D FISHER MD DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD, DMD
Authorized Official - Phone:302-644-2977
Mailing Address - Street 1:17605 NASSAU COMMONS BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958-6284
Mailing Address - Country:US
Mailing Address - Phone:302-644-2977
Mailing Address - Fax:302-645-7561
Practice Address - Street 1:17605 NASSAU COMMONS BLVD STE C
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958-6284
Practice Address - Country:US
Practice Address - Phone:302-644-2977
Practice Address - Fax:302-645-7561
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-24
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE20001065631223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000015026Medicaid
DE1000015026Medicaid