Healthcare Provider Details

I. General information

NPI: 1972910479
Provider Name (Legal Business Name): MARC BONGARD DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2014
Last Update Date: 07/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 55TH ST
BROOKLYN NY
11220-2508
US

IV. Provider business mailing address

277 GOLD ST APT 7H
BROOKLYN NY
11201-3114
US

V. Phone/Fax

Practice location:
  • Phone: 718-630-7000
  • Fax:
Mailing address:
  • Phone: 857-488-6131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License NumberP93870
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: