Provider Demographics
NPI:1063634988
Name:BRAL, POURANG
Entity Type:Individual
Prefix:
First Name:POURANG
Middle Name:
Last Name:BRAL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 ALBION ST
Mailing Address - Street 2:
Mailing Address - City:PASSAIC
Mailing Address - State:NJ
Mailing Address - Zip Code:07055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:901 BERGEN AVE
Practice Address - Street 2:2ND FLOOR
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306
Practice Address - Country:US
Practice Address - Phone:201-222-1123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJDI19857122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7165803Medicaid