Provider Demographics
NPI:1073966545
Name:NACK, BRYAN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:
Last Name:NACK
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 1:1600 S ANDREWS AVE
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2510
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:609 HARPER AVE
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3206
Practice Address - Country:US
Practice Address - Phone:267-736-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN221671223S0112X
390200000X
PADS0425041223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program