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General NPI Number Information
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NPI Number | 1265585046
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Entity Type | Organization
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Legal Business Name | DELAWARE MODERN DENTAL
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Dates
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Enumeration Date | 01/18/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 850 LIBRARY AVE SUITE 102
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City | NEWARK
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State | DE
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Zip | 19711-7170
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Country | US
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Telephone | 302-366-8668
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Fax | 302-366-8081
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Provider Business Mailing Address
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Address Line | 850 LIBRARY AVE SUITE 102
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City | NEWARK
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State | DE
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Zip | 19711-7170
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Country | US
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Telephone | 302-366-8668
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Fax | 302-366-8081
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Authorized Official
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Title or Position | DENTIST
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Name | DR. LISA FAGIOLETTI
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Credential | D.M.D.
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Telephone | 302-366-8668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 2005207645
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License Number State | DE
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