MEDICARE: DR. GEORGE T DERENZO D.D.S.

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	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	G1-0001106	DE
2	1223P0221X	Pediatric Dentistry	G1-0001106	DE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811047962
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GEORGE T DERENZO D.D.S.

Provider Business Mailing Address
First Line	:	3079 SANTORINI CT
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34119-7708
Country	:	US
Telephone Number	:	302-354-6699
Fax Number	:

Provider Business Practice Location Address
First Line	:	4201 MILLER RD
Second Line	:
City	:	WILMINGTON
State	:	DE
Zip	:	19802-1914
Country	:	US
Telephone Number	:	302-354-6699
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2007
Last Update Date	:	04/25/2024

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