MEDICARE: DR. JORGE L DELVALLE D.M.D

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	1223G0001X	General Practice Dentistry	22DI02479400	NJ

General Provider Information

NPI Number	:	1205116175
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JORGE L DELVALLE D.M.D

Provider Business Mailing Address
First Line	:	25 AVE AT PORT IMPERIAL
Second Line	:	APT. 621
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-8350
Country	:	US
Telephone Number	:	201-803-6647
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 AVE AT PORT IMPERIAL
Second Line	:	APT. 621
City	:	WEST NEW YORK
State	:	NJ
Zip	:	07093-8350
Country	:	US
Telephone Number	:	201-803-6647
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/24/2011
Last Update Date	:	08/24/2011

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