MEDICARE: DR. STACI BRUNELL DMD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	059881	NY
2	390200000X	Student in an Organized Health Care Education/Training Program
3	1223P0221X	Pediatric Dentistry	059881	NY

General Provider Information

NPI Number	:	1306366083
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. STACI BRUNELL DMD

Provider Business Mailing Address
First Line	:	1974 MAPLE HILL ST # A
Second Line	:
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-4190
Country	:	US
Telephone Number	:	914-245-1670
Fax Number	:

Provider Business Practice Location Address
First Line	:	1974 MAPLE HILL ST # A
Second Line	:
City	:	YORKTOWN HEIGHTS
State	:	NY
Zip	:	10598-4190
Country	:	US
Telephone Number	:	914-245-1670
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/22/2017
Last Update Date	:	09/11/2020

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