Provider Demographics
NPI:1811202245
Name:BONCZEK, BRIAN R (DMD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:BONCZEK
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:PO BOX 3189
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13220-3189
Mailing Address - Country:US
Mailing Address - Phone:315-454-6000
Mailing Address - Fax:
Practice Address - Street 1:100 PRICEDALE RD
Practice Address - Street 2:
Practice Address - City:BELLE VERNON
Practice Address - State:PA
Practice Address - Zip Code:15012-1968
Practice Address - Country:US
Practice Address - Phone:724-929-4939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS0384061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice