Provider Demographics
NPI:1760807309
Name:ERICA BRONITSKY, DMD, LLC
Entity Type:Organization
Organization Name:ERICA BRONITSKY, DMD, LLC
Other - Org Name:BRONITSKY FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:ERICA
Authorized Official - Middle Name:B
Authorized Official - Last Name:BRONITSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, LLC
Authorized Official - Phone:503-649-5665
Mailing Address - Street 1:17952 SW BLANTON ST
Mailing Address - Street 2:
Mailing Address - City:ALOHA
Mailing Address - State:OR
Mailing Address - Zip Code:97007-1329
Mailing Address - Country:US
Mailing Address - Phone:503-649-5665
Mailing Address - Fax:503-649-6857
Practice Address - Street 1:17952 SW BLANTON ST
Practice Address - Street 2:
Practice Address - City:ALOHA
Practice Address - State:OR
Practice Address - Zip Code:97007-1329
Practice Address - Country:US
Practice Address - Phone:503-649-5665
Practice Address - Fax:503-649-6857
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-18
Last Update Date:2014-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD91381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty