Provider Demographics
NPI:1659430643
Name:BOVINO, BRIAN F (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:F
Last Name:BOVINO
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 1:19 HIDDEN GLEN RD
Mailing Address - Street 2:
Mailing Address - City:UPPER SADDLE RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:07458-1722
Mailing Address - Country:US
Mailing Address - Phone:201-818-6953
Mailing Address - Fax:201-818-4118
Practice Address - Street 1:425 W 59TH ST
Practice Address - Street 2:10TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1104
Practice Address - Country:US
Practice Address - Phone:212-523-7791
Practice Address - Fax:212-523-8165
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0405181223S0112X
NJ0151091223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01285336Medicaid
NY01285336Medicaid
NYD5H651Medicare PIN