MEDICARE: BRANDYWINE DENTAL OF THE LEHIGH VALLEY, LLC

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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1932779196
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRANDYWINE DENTAL OF THE LEHIGH VALLEY, LLC

Provider Business Mailing Address
First Line	:	9655 LONGSWAMP RD
Second Line	:
City	:	MERTZTOWN
State	:	PA
Zip	:	19539-8800
Country	:	US
Telephone Number	:	610-682-6386
Fax Number	:	610-682-6387

Provider Business Practice Location Address
First Line	:	9655 LONGSWAMP RD
Second Line	:
City	:	MERTZTOWN
State	:	PA
Zip	:	19539-8800
Country	:	US
Telephone Number	:	610-682-6386
Fax Number	:	610-682-6387

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	MICHAEL E KUN
Credential	:	DMD
Telephone Number	:	610-682-6386

Provider Enumeration Date	:	06/30/2021
Last Update Date	:	06/30/2021

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