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General NPI Number Information
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NPI Number | 1124358551
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Entity Type | Organization
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Legal Business Name | 34TH STREET DENTAL CARE
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Dates
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Enumeration Date | 01/07/2010
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Last Update Date | 01/07/2010
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Provider Practice Location Address
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Address Line | 6411 34TH ST
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City | BERWYN
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State | IL
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Zip | 60402-3717
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Country | US
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Telephone | 708-484-6576
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Fax | 708-484-0843
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Provider Business Mailing Address
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Address Line | 6411 34TH ST
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City | BERWYN
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State | IL
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Zip | 60402-3717
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Country | US
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Telephone | 708-484-6576
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Fax | 708-484-0843
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Authorized Official
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Title or Position | OWNER
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Name | DR. ANTHONY A BRUCCI
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Credential | DMD
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Telephone | 708-484-6576
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 019023728
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License Number State | IL
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