Provider Demographics
NPI:1154461689
Name:MARZULLO, BRUCE D (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:D
Last Name:MARZULLO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 LAGRANGE AVENUE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603
Mailing Address - Country:US
Mailing Address - Phone:845-452-2900
Mailing Address - Fax:845-452-4974
Practice Address - Street 1:43 LAGRANGE AVENUE
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603
Practice Address - Country:US
Practice Address - Phone:845-452-2900
Practice Address - Fax:845-452-4974
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0373831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01017770Medicaid
NY01017770Medicaid
NYD26461Medicare ID - Type Unspecified