MEDICARE: BRANDYWINE VALLEY ORAL & MAXIOLLOFACIAL SURGERY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200631	OTHER	PA	KEYSTONE CENTRAL
2	0132579000	OTHER	PA	KEYSTONE EAST
3	02628400	OTHER	PA	CAPITAL BLUE CROSS

General Provider Information

NPI Number	:	1568563088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANDYWINE VALLEY ORAL & MAXIOLLOFACIAL SURGERY

Provider Business Mailing Address
First Line	:	5279 LINCOLN HWY
Second Line	:
City	:	GAP
State	:	PA
Zip	:	17527-9427
Country	:	US
Telephone Number	:	717-442-9537
Fax Number	:	717-442-8311

Provider Business Practice Location Address
First Line	:	5279 LINCOLN HWY
Second Line	:
City	:	GAP
State	:	PA
Zip	:	17527-9427
Country	:	US
Telephone Number	:	717-442-9537
Fax Number	:	717-442-8311

Authorized Official
Title or Position	:	OWNER/DOCTOR
Name	:	DR. ROBERT D WHITLEY
Credential	:	D.D.D.
Telephone Number	:	717-442-9537

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	08/22/2020

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Directions to “BRANDYWINE VALLEY ORAL & MAXIOLLOFACIAL SURGERY ” Practice Location

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