Basic Information
| Provider Information | |||||||||
| NPI: | 1003805748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRANCA | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 ALEXANDER AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAKE GROVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117550429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312656655 | ||||||||
| FaxNumber: | 6312659735 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 ALEXANDER AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | LAKE GROVE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117550429 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6312656655 | ||||||||
| FaxNumber: | 6312659735 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/16/2005 | ||||||||
| LastUpdateDate: | 04/02/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 040425 | NY | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 040425 | 01 | NY | LIC # | OTHER |