Healthcare Provider Details

I. General information

NPI: 1538159645
Provider Name (Legal Business Name): ROMAN B. CYBAK D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/28/2005
Last Update Date: 08/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BOX 6673 RAF LAKENHEATH
BRANDON SUFFOLK
IP279PN
GB

IV. Provider business mailing address

BOX 6673 RAF LAKENHEATH
BRANDON SUFFOLK
IP279PN
GB

V. Phone/Fax

Practice location:
  • Phone: 01144163852
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDS023891-L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: