Healthcare Provider Details

I. General information

NPI: 1518205137
Provider Name (Legal Business Name): DELAWARE ORAL & MAXILLOFACIAL SURGERY,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2013
Last Update Date: 01/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 BIDDLE AVE 214
NEWARK DE
19702-3968
US

IV. Provider business mailing address

200 BIDDLE AVE 214
NEWARK DE
19702-3968
US

V. Phone/Fax

Practice location:
  • Phone: 302-595-4642
  • Fax: 302-595-4648
Mailing address:
  • Phone: 302-595-4642
  • Fax: 302-595-4648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: DR. SAMUEL C NWOGU
Title or Position: ORAL & MAXILLOFACIAL SURGEON/OWNER
Credential: D.D.S.
Phone: 302-595-4642