Healthcare Provider Details

I. General information

NPI: 1194756320
Provider Name (Legal Business Name): DENNIS RAY BANDUCCI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 08/30/2020
Certification Date: 08/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 N FRONT ST
HARRISBURG PA
17110-1222
US

IV. Provider business mailing address

100 N ACADEMY AVE
DANVILLE PA
17822-4903
US

V. Phone/Fax

Practice location:
  • Phone: 717-233-4691
  • Fax: 717-233-8836
Mailing address:
  • Phone: 570-271-6144
  • Fax: 570-271-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberMD-04125-E
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberMD041256E
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: