MEDICARE: DR. GEORGE T. DERENZO

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	G1-0001106	DE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1972720373
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. GEORGE T. DERENZO

Provider Business Mailing Address
First Line	:	2000 FOULK RD
Second Line	:	SUITE C
City	:	WILMINGTON
State	:	DE
Zip	:	19810-3642
Country	:	US
Telephone Number	:	302-475-3110
Fax Number	:	302-475-5206

Provider Business Practice Location Address
First Line	:	2000 FOULK RD
Second Line	:	SUITE C
City	:	WILMINGTON
State	:	DE
Zip	:	19810-3642
Country	:	US
Telephone Number	:	302-475-3110
Fax Number	:	302-475-5206

Authorized Official
Title or Position	:	OWNER
Name	:	MR. GEORGE T DERENZO
Credential	:	D.D.S.
Telephone Number	:	302-475-3110

Provider Enumeration Date	:	04/19/2007
Last Update Date	:	01/20/2012

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