Provider Demographics
NPI:1689370843
Name:URSOMANNO, BRENDON L
Entity Type:Individual
Prefix:DR
First Name:BRENDON
Middle Name:L
Last Name:URSOMANNO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 SPARKILL AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-3134
Mailing Address - Country:US
Mailing Address - Phone:718-987-7920
Mailing Address - Fax:
Practice Address - Street 1:317 NJ-34
Practice Address - Street 2:SUITE 203
Practice Address - City:COLTS NECK
Practice Address - State:NJ
Practice Address - Zip Code:07722
Practice Address - Country:US
Practice Address - Phone:732-677-2777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI029394001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice