Provider Demographics
NPI:1033426507
Name:BRUCK, RONNI DARA (DMD)
Entity Type:Individual
Prefix:DR
First Name:RONNI
Middle Name:DARA
Last Name:BRUCK
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1830 LOMBARD ST
Mailing Address - Street 2:APT 8A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-4003
Mailing Address - Country:US
Mailing Address - Phone:267-253-3048
Mailing Address - Fax:
Practice Address - Street 1:403 WASHINGTON LN
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3123
Practice Address - Country:US
Practice Address - Phone:215-576-5805
Practice Address - Fax:215-576-8998
Is Sole Proprietor?:No
Enumeration Date:2010-09-07
Last Update Date:2010-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0367691223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics