Provider Demographics
NPI:1154443026
Name:MITCHELL BRUDNO DMD LLC
Entity Type:Organization
Organization Name:MITCHELL BRUDNO DMD LLC
Other - Org Name:LLC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER SOLE MEMBER LLC
Authorized Official - Prefix:
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUDNO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-429-4249
Mailing Address - Street 1:1021 MARLTON PIKE WEST
Mailing Address - Street 2:
Mailing Address - City:CHERRY HILL
Mailing Address - State:NJ
Mailing Address - Zip Code:08002
Mailing Address - Country:US
Mailing Address - Phone:856-429-4249
Mailing Address - Fax:
Practice Address - Street 1:1021 MARLTON PIKE WEST
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002
Practice Address - Country:US
Practice Address - Phone:856-429-4249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJDI15818122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty