MEDICARE: DELAWARE PEDIATRIC DENTISTRY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0221X	Pediatric Dentistry

General Provider Information

NPI Number	:	1063971745
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DELAWARE PEDIATRIC DENTISTRY

Provider Business Mailing Address
First Line	:	117 TUSCANY DR
Second Line	:
City	:	MIDDLETOWN
State	:	DE
Zip	:	19709-7856
Country	:	US
Telephone Number	:	954-330-1525
Fax Number	:

Provider Business Practice Location Address
First Line	:	625 N DUPONT BLVD
Second Line	:
City	:	MILFORD
State	:	DE
Zip	:	19963-1099
Country	:	US
Telephone Number	:	954-330-1525
Fax Number	:

Authorized Official
Title or Position	:	PEDIATRIC DENTIST
Name	:	DR. GERARDO MARTINEZ
Credential	:	DMD
Telephone Number	:	954-330-1525

Provider Enumeration Date	:	03/13/2019
Last Update Date	:	03/13/2019

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