Provider Demographics
NPI:1922127232
Name:FIRST STATE ORAL AND MAXILLOFACIAL SURGERY CORP
Entity Type:Organization
Organization Name:FIRST STATE ORAL AND MAXILLOFACIAL SURGERY CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:DITTY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, MD
Authorized Official - Phone:302-674-4450
Mailing Address - Street 1:1004 S STATE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-6901
Mailing Address - Country:US
Mailing Address - Phone:302-674-4450
Mailing Address - Fax:302-678-3228
Practice Address - Street 1:1004 S STATE ST STE 1
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-6901
Practice Address - Country:US
Practice Address - Phone:302-674-4450
Practice Address - Fax:302-678-3228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1000931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1000039185Medicaid
DEI47441Medicare ID - Type Unspecified
DE1000039185Medicaid