Healthcare Provider Details

I. General information

NPI: 1568563088
Provider Name (Legal Business Name): BRANDYWINE VALLEY ORAL & MAXIOLLOFACIAL SURGERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5279 LINCOLN HWY
GAP PA
17527-9427
US

IV. Provider business mailing address

5279 LINCOLN HWY
GAP PA
17527-9427
US

V. Phone/Fax

Practice location:
  • Phone: 717-442-9537
  • Fax: 717-442-8311
Mailing address:
  • Phone: 717-442-9537
  • Fax: 717-442-8311

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. ROBERT D WHITLEY
Title or Position: OWNER/DOCTOR
Credential: D.D.D.
Phone: 717-442-9537