Provider Demographics
NPI:1922518059
Name:WILMINGTON ORTHODONTIC CENTER
Entity Type:Organization
Organization Name:WILMINGTON ORTHODONTIC CENTER
Other - Org Name:SOUTHERN DELAWARE DENTAL SPECIALISTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:PANCKO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-855-9499
Mailing Address - Street 1:20785 PROFESSIONAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19947-3198
Mailing Address - Country:US
Mailing Address - Phone:302-855-9499
Mailing Address - Fax:
Practice Address - Street 1:20785 PROFESSIONAL PARK BLVD
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:DE
Practice Address - Zip Code:19947-3198
Practice Address - Country:US
Practice Address - Phone:302-855-9499
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-03
Last Update Date:2017-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
122300000X, 1223P0221X
DE1223P0300X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty