Provider Demographics
NPI:1437414034
Name:BRONG, NICHOLAS PHILIP (DDS)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:PHILIP
Last Name:BRONG
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 1:800 MARIE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55075-2055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:800 MARIE AVE
Practice Address - Street 2:
Practice Address - City:SOUTH SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55075-2055
Practice Address - Country:US
Practice Address - Phone:651-451-1277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND131381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice