Provider Demographics
NPI:1760413504
Name:BRUSCO, PETER (DMD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BRUSCO
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 1:170 KINNELON RD RM 29A
Mailing Address - Street 2:
Mailing Address - City:KINNELON
Mailing Address - State:NJ
Mailing Address - Zip Code:07405-2351
Mailing Address - Country:US
Mailing Address - Phone:973-838-5862
Mailing Address - Fax:973-283-0724
Practice Address - Street 1:170 KINNELON RD RM 29A
Practice Address - Street 2:
Practice Address - City:KINNELON
Practice Address - State:NJ
Practice Address - Zip Code:07405-2351
Practice Address - Country:US
Practice Address - Phone:973-838-5862
Practice Address - Fax:973-283-0724
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22D1012808001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice