Provider Demographics
NPI:1689242778
Name:BRUNGO, VICTORIA LEE (DMD)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:LEE
Last Name:BRUNGO
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4137 LEECHBURG RD
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-2305
Mailing Address - Country:US
Mailing Address - Phone:724-335-1232
Mailing Address - Fax:
Practice Address - Street 1:4137 LEECHBURG RD
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-2305
Practice Address - Country:US
Practice Address - Phone:724-335-1232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAA00030891981223G0001X
PADS0431951223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice