MEDICARE: DR. MARK DAVID BRONNER DMD

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	DN11941	FL

General Provider Information

NPI Number	:	1528269701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK DAVID BRONNER DMD

Provider Business Mailing Address
First Line	:	1105 MOON LAKE DR
Second Line	:
City	:	NAPLES
State	:	FL
Zip	:	34104-6606
Country	:	US
Telephone Number	:	239-434-8916
Fax Number	:

Provider Business Practice Location Address
First Line	:	26800 S TAMIAMI TRL
Second Line	:	240
City	:	BONITA SPRINGS
State	:	FL
Zip	:	34134-4349
Country	:	US
Telephone Number	:	239-498-1105
Fax Number	:

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

Provider Enumeration Date	:	05/29/2007
Last Update Date	:	07/08/2007

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