Healthcare Provider Details

I. General information

NPI: 1356432769
Provider Name (Legal Business Name): MARK J BRONSKY D.M.D., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 PARK AVE STE 1G
NEW YORK NY
10021-8015
US

IV. Provider business mailing address

530 PARK AVE STE 1G
NEW YORK NY
10021-8015
US

V. Phone/Fax

Practice location:
  • Phone: 212-758-0040
  • Fax: 212-758-7771
Mailing address:
  • Phone: 212-758-0040
  • Fax: 212-758-7771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number043039
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: