Provider Demographics
NPI:1740235449
Name:CHRISTIANA CENTER FOR ORAL & MAXILLOFACIAL SURGERY, P.A.
Entity Type:Organization
Organization Name:CHRISTIANA CENTER FOR ORAL & MAXILLOFACIAL SURGERY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:DAMICO
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-292-1600
Mailing Address - Street 1:4133 STANTON OGLETWN RD STE 200
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-4187
Mailing Address - Country:US
Mailing Address - Phone:302-292-1600
Mailing Address - Fax:302-319-5954
Practice Address - Street 1:4133 OGLETOWN STANTON RD STE 200
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-4187
Practice Address - Country:US
Practice Address - Phone:130-232-8677
Practice Address - Fax:023-195-9543
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00009521223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000540991OtherHIGHMARK BLUE SHIELD
DE0000189002Medicaid
4300241OtherAETNA
DE199367325OtherCAREFIRST BLUE CROSS BLUE SHIELD OF DELAWARE
0116093000OtherAMERIHEALTH
4300241OtherAETNA