Provider Demographics
NPI:1801110812
Name:BENSALEM DENTAL GROUP
Entity type:Organization
Organization Name:BENSALEM DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:V
Authorized Official - Last Name:BROGNA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD, FAGD
Authorized Official - Phone:215-638-3350
Mailing Address - Street 1:1044 BYBERRY RD
Mailing Address - Street 2:
Mailing Address - City:BENSALEM
Mailing Address - State:PA
Mailing Address - Zip Code:19020-3922
Mailing Address - Country:US
Mailing Address - Phone:215-638-3350
Mailing Address - Fax:215-638-0336
Practice Address - Street 1:1044 BYBERRY RD
Practice Address - Street 2:
Practice Address - City:BENSALEM
Practice Address - State:PA
Practice Address - Zip Code:19020-3922
Practice Address - Country:US
Practice Address - Phone:215-638-3350
Practice Address - Fax:215-638-0336
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-19
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS035996122300000X
PADS036855122300000X
PADS027317122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty