=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063971745
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DELAWARE PEDIATRIC DENTISTRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2019
-----------------------------------------------------
Last Update Date | 03/13/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 N DUPONT BLVD
-----------------------------------------------------
City | MILFORD
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19963-1099
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-330-1525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 TUSCANY DR
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19709-7856
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-330-1525
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC DENTIST
-----------------------------------------------------
Name | DR. GERARDO MARTINEZ
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 954-330-1525
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------