Healthcare Provider Details

I. General information

NPI: 1013089895
Provider Name (Legal Business Name): STATE OF DELAWARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 03/05/2026
Certification Date: 03/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 FEDERAL ST
DOVER DE
19901-3635
US

IV. Provider business mailing address

417 FEDERAL ST
DOVER DE
19901-3635
US

V. Phone/Fax

Practice location:
  • Phone: 302-744-4849
  • Fax: 302-739-1613
Mailing address:
  • Phone: 302-744-4861
  • Fax: 302-739-1613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: GARY ALSTON OWENS II
Title or Position: FISCAL MANAGER
Credential:
Phone: 302-744-4861