Provider Demographics
NPI:1689700775
Name:DIAMOND STATE DENTISTRY
Entity Type:Organization
Organization Name:DIAMOND STATE DENTISTRY
Other - Org Name:LUCINDA K BUNTING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCINDA
Authorized Official - Middle Name:K
Authorized Official - Last Name:BUNTING
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:302-424-7976
Mailing Address - Street 1:215 WEST LIBERTY WAY
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19963
Mailing Address - Country:US
Mailing Address - Phone:302-424-7976
Mailing Address - Fax:302-424-2324
Practice Address - Street 1:215 WEST LIBERTY WAY
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963
Practice Address - Country:US
Practice Address - Phone:302-424-7976
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE1023122300000X
122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE100023496Medicaid
DE728083OtherUNITED CONCORDIA
DE=========OtherTAX ID