MEDICARE: BRUNSWICK DENTAL GROUP

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	122300000X	Dentist	22DI02412000	NJ

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285017624
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUNSWICK DENTAL GROUP

Provider Business Mailing Address
First Line	:	415 STATE ROUTE 18
Second Line	:	SUITE 13
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-2305
Country	:	US
Telephone Number	:	732-955-6907
Fax Number	:	732-955-6837

Provider Business Practice Location Address
First Line	:	415 STATE ROUTE 18
Second Line	:	SUITE 13
City	:	EAST BRUNSWICK
State	:	NJ
Zip	:	08816-2305
Country	:	US
Telephone Number	:	732-955-6907
Fax Number	:	732-955-6837

Authorized Official
Title or Position	:	DOCTOR
Name	:	DR. KATHERINE VARCHENKO
Credential	:	DMD
Telephone Number	:	732-955-6907

Provider Enumeration Date	:	07/02/2015
Last Update Date	:	07/02/2015

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Directions to “BRUNSWICK DENTAL GROUP ” Practice Location

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