Provider Demographics
NPI:1124358551
Name:34TH STREET DENTAL CARE
Entity Type:Organization
Organization Name:34TH STREET DENTAL CARE
Other - Org Name:34TH STREET DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRUCCI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:708-484-6576
Mailing Address - Street 1:6411 34TH ST
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3717
Mailing Address - Country:US
Mailing Address - Phone:708-484-6576
Mailing Address - Fax:708-484-0843
Practice Address - Street 1:6411 34TH ST
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3717
Practice Address - Country:US
Practice Address - Phone:708-484-6576
Practice Address - Fax:708-484-0843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-07
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190237281223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty