Provider Demographics
NPI:1043655335
Name:DEMIANCZYK, DEREK (DMD)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:DEMIANCZYK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:357 S GULPH RD STE 110
Mailing Address - Street 2:
Mailing Address - City:KING OF PRUSSIA
Mailing Address - State:PA
Mailing Address - Zip Code:19406-3174
Mailing Address - Country:US
Mailing Address - Phone:610-337-2325
Mailing Address - Fax:
Practice Address - Street 1:357 S GULPH RD STE 110
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3174
Practice Address - Country:US
Practice Address - Phone:610-337-2325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-01
Last Update Date:2020-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS040025122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist