Provider Demographics
NPI:1780183079
Name:LEDNER, BRYCE MAXWELL (DDS)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:MAXWELL
Last Name:LEDNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 HARBOR PARK DR
Mailing Address - Street 2:
Mailing Address - City:CENTERPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11721-1640
Mailing Address - Country:US
Mailing Address - Phone:516-356-6670
Mailing Address - Fax:
Practice Address - Street 1:496 SMITHTOWN BYP STE 300
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-5012
Practice Address - Country:US
Practice Address - Phone:631-360-8000
Practice Address - Fax:631-724-7988
Is Sole Proprietor?:No
Enumeration Date:2018-02-01
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0609471223G0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1223G0001XDental ProvidersDentistGeneral Practice