Provider Demographics
NPI:1255484879
Name:BRODIS, ANDREW MARK (DMD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:MARK
Last Name:BRODIS
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 1:31 BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-2008
Mailing Address - Country:US
Mailing Address - Phone:814-362-2100
Mailing Address - Fax:814-368-8683
Practice Address - Street 1:31 BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-2008
Practice Address - Country:US
Practice Address - Phone:814-362-2100
Practice Address - Fax:814-368-8683
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADSO19122L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist