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General NPI Number Information
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NPI Number | 1922127232
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Entity Type | Organization
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Legal Business Name | FIRST STATE ORAL AND MAXILLOFACIAL SURGERY CORP
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 11/05/2019
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Provider Practice Location Address
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Address Line | 1004 S STATE ST STE 1
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City | DOVER
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State | DE
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Zip | 19901-6901
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Country | US
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Telephone | 302-674-4450
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Fax | 302-678-3228
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Provider Business Mailing Address
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Address Line | 1004 S STATE ST STE 1
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City | DOVER
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State | DE
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Zip | 19901-6901
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Country | US
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Telephone | 302-674-4450
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Fax | 302-678-3228
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Authorized Official
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Title or Position | OWNER
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Name | DR. DOUGLAS LYNN DITTY
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Credential | DMD, MD
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Telephone | 302-674-4450
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | G100093
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License Number State | DE
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