Provider Demographics
NPI:1760792766
Name:DELAWARE VALLEY ORAL & MAXILLOFACIAL SURGICAL ASSOCIATES
Entity Type:Organization
Organization Name:DELAWARE VALLEY ORAL & MAXILLOFACIAL SURGICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:A
Authorized Official - Last Name:ILACQUA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:610-275-0500
Mailing Address - Street 1:2603 DEKALB PIKE
Mailing Address - Street 2:
Mailing Address - City:NORRISTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19401-1818
Mailing Address - Country:US
Mailing Address - Phone:610-275-0500
Mailing Address - Fax:610-275-1054
Practice Address - Street 1:2603 DEKALB PIKE
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19401-1818
Practice Address - Country:US
Practice Address - Phone:610-275-0500
Practice Address - Fax:610-275-1054
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-12
Last Update Date:2010-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS019424L1223S0112X
PADS022706L1223S0112X
PADS022786L1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA112651Medicare PIN
PA085724Medicare PIN
PA094462Medicare PIN