Healthcare Provider Details

I. General information

NPI: 1316095904
Provider Name (Legal Business Name): CHILDREN'S DENTAL HEALTH OF DELAWARE - WILMINGTON, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 02/10/2021
Certification Date: 02/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

708 FOULK RD
WILMINGTON DE
19803-3734
US

IV. Provider business mailing address

200 WILLOWBROOK LN STE 220
WEST CHESTER PA
19382-5697
US

V. Phone/Fax

Practice location:
  • Phone: 302-764-7714
  • Fax:
Mailing address:
  • Phone: 267-575-2321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License NumberG1-0000893
License Number StateDE
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberG1-0000909
License Number StateDE

VIII. Authorized Official

Name: VAN PHI LE
Title or Position: CREDENTIALING CONTRACTS MANAGER
Credential:
Phone: 267-575-2321