Provider Demographics
NPI:1265276257
Name:KUPCHAK, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:KUPCHAK
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 1:10501 MONTROSE AVE APT 204
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-4141
Mailing Address - Country:US
Mailing Address - Phone:860-967-6609
Mailing Address - Fax:
Practice Address - Street 1:8930 BROWN DRIVE HOSPITAL DENTISTRY BLDG 9, 2ND FLOOR
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0001
Practice Address - Country:US
Practice Address - Phone:860-967-6609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-24
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14052122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist