Healthcare Provider Details

I. General information

NPI: 1043655335
Provider Name (Legal Business Name): DEREK DEMIANCZYK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 12/30/2020
Certification Date: 12/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

357 S GULPH RD STE 110
KING OF PRUSSIA PA
19406-3174
US

IV. Provider business mailing address

357 S GULPH RD STE 110
KING OF PRUSSIA PA
19406-3174
US

V. Phone/Fax

Practice location:
  • Phone: 610-337-2325
  • Fax:
Mailing address:
  • Phone: 610-337-2325
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS040025
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS040025
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: