Healthcare Provider Details

I. General information

NPI: 1336788389
Provider Name (Legal Business Name): BRIAN BONCZEK DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2019
Last Update Date: 12/22/2019
Certification Date: 12/22/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3392 SAXONBURG BLVD STE 440
GLENSHAW PA
15116-3148
US

IV. Provider business mailing address

1332 POCONO ST
PITTSBURGH PA
15218-1114
US

V. Phone/Fax

Practice location:
  • Phone: 412-767-4403
  • Fax:
Mailing address:
  • Phone: 412-913-9550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. BRIAN BONCZEK
Title or Position: DENTIST
Credential: DMD
Phone: 412-913-9550