Provider Demographics
NPI:1699235937
Name:BRANDYWINE PEDIATRIC DENTISTRY, P.A.
Entity type:Organization
Organization Name:BRANDYWINE PEDIATRIC DENTISTRY, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JILL
Authorized Official - Middle Name:L
Authorized Official - Last Name:GARRIDO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:302-475-3110
Mailing Address - Street 1:2000 FOULK RD STE C
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19810-3642
Mailing Address - Country:US
Mailing Address - Phone:302-475-3110
Mailing Address - Fax:
Practice Address - Street 1:2000 FOULK RD STE C
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19810-3642
Practice Address - Country:US
Practice Address - Phone:302-475-3110
Practice Address - Fax:302-475-5206
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-22
Last Update Date:2019-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1003109877Medicaid