Provider Demographics
NPI:1972720373
Name:DR. GEORGE T. DERENZO
Entity Type:Organization
Organization Name:DR. GEORGE T. DERENZO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:T
Authorized Official - Last Name:DERENZO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-475-3110
Mailing Address - Street 1:2000 FOULK RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-3642
Mailing Address - Country:US
Mailing Address - Phone:302-475-3110
Mailing Address - Fax:302-475-5206
Practice Address - Street 1:2000 FOULK RD
Practice Address - Street 2:SUITE C
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-3642
Practice Address - Country:US
Practice Address - Phone:302-475-3110
Practice Address - Fax:302-475-5206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00011061223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001060631Medicaid