Provider Demographics
NPI:1164408662
Name:BRUYCKER DASILVA, MARCELO
Entity Type:Individual
Prefix:
First Name:MARCELO
Middle Name:
Last Name:BRUYCKER DASILVA
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 1:720 PITCHERS WAY
Mailing Address - Street 2:#B 21
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-6706
Mailing Address - Country:US
Mailing Address - Phone:508-790-2565
Mailing Address - Fax:
Practice Address - Street 1:30 ELM AVE
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5547
Practice Address - Country:US
Practice Address - Phone:508-778-0300
Practice Address - Fax:508-778-8747
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7987122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist