Provider Demographics
NPI:1316095904
Name:CHILDREN'S DENTAL HEALTH OF DELAWARE - WILMINGTON, PA
Entity type:Organization
Organization Name:CHILDREN'S DENTAL HEALTH OF DELAWARE - WILMINGTON, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING CONTRACTS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:VAN PHI
Authorized Official - Middle Name:
Authorized Official - Last Name:LE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-575-2321
Mailing Address - Street 1:200 WILLOWBROOK LN STE 220
Mailing Address - Street 2:
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19382-5697
Mailing Address - Country:US
Mailing Address - Phone:267-575-2321
Mailing Address - Fax:
Practice Address - Street 1:708 FOULK RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19803-3734
Practice Address - Country:US
Practice Address - Phone:302-764-7714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-08
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEG1-00009091223P0221X
DEG1-00008931223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000443701Medicaid
DE0000651508Medicaid