=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801110812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BENSALEM DENTAL GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2010
-----------------------------------------------------
Last Update Date | 03/19/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1044 BYBERRY RD
-----------------------------------------------------
City | BENSALEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19020-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-638-3350
-----------------------------------------------------
Fax | 215-638-0336
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1044 BYBERRY RD
-----------------------------------------------------
City | BENSALEM
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19020-3922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-638-3350
-----------------------------------------------------
Fax | 215-638-0336
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MICHAEL V BROGNA
-----------------------------------------------------
Credential | D.M.D., F.A.G.D
-----------------------------------------------------
Telephone | 215-638-3350
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS035996
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS036855
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | DS027317
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------