MEDICARE: SERGIEI BROUNTCHENKO DDS

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	42278	CA

General Provider Information

NPI Number	:	1740272970
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SERGIEI BROUNTCHENKO DDS

Provider Business Mailing Address
First Line	:	4577 E KINGS CANYON RD, SUITE #102
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93702-3717
Country	:	US
Telephone Number	:	559-454-0777
Fax Number	:	559-454-0280

Provider Business Practice Location Address
First Line	:	4577 E KINGS CANYON RD, SUITE #102
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93702-3717
Country	:	US
Telephone Number	:	559-454-0777
Fax Number	:	559-454-0280

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

Provider Enumeration Date	:	08/15/2005
Last Update Date	:	03/12/2020

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