Healthcare Provider Details

I. General information

NPI: 1134328172
Provider Name (Legal Business Name): DIANA BRONSTEIN DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2007
Last Update Date: 06/27/2021
Certification Date: 06/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16669 SUNBURST LAKE ST
WIMAUMA FL
33598-5566
US

IV. Provider business mailing address

16669 SUNBURST LAKE ST
WIMAUMA FL
33598-5566
US

V. Phone/Fax

Practice location:
  • Phone: 561-344-3916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN18020
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: