Provider Demographics
NPI:1588643688
Name:CONICELLA, BRUNO C (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUNO
Middle Name:C
Last Name:CONICELLA
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 1:701 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15215-2238
Mailing Address - Country:US
Mailing Address - Phone:412-782-3288
Mailing Address - Fax:412-783-3879
Practice Address - Street 1:701 MAIN ST
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15215-2238
Practice Address - Country:US
Practice Address - Phone:412-782-3288
Practice Address - Fax:412-783-3879
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS025520L122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001110778003Medicaid