Healthcare Provider Details

I. General information

NPI: 1073814091
Provider Name (Legal Business Name): ADELE BRONKHORST BCHD, MDENT (ORTHO)
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2010
Last Update Date: 11/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 LONGWOOD AVE # HU-226
BOSTON MA
02115-5724
US

IV. Provider business mailing address

300 LONGWOOD AVE # HU-226
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 857-218-5540
  • Fax: 617-730-0478
Mailing address:
  • Phone: 857-218-5540
  • Fax: 617-730-0478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberDL11164
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: