Healthcare Provider Details

I. General information

NPI: 1265276257
Provider Name (Legal Business Name): BRIAN KUPCHAK
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 BROWN DRIVE HOSPITAL DENTISTRY BLDG 9, 2ND FLOOR
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

10501 MONTROSE AVE APT 204
BETHESDA MD
20814-4141
US

V. Phone/Fax

Practice location:
  • Phone: 860-967-6609
  • Fax:
Mailing address:
  • Phone: 860-967-6609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number14052
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: