Provider Demographics
NPI:1194756320
Name:BANDUCCI, DENNIS RAY (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:RAY
Last Name:BANDUCCI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:2807 N FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17110-1222
Practice Address - Country:US
Practice Address - Phone:717-233-4691
Practice Address - Fax:717-233-8836
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2020-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD-04125-E208200000X
PAMD041256E2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001127882004Medicaid
PA193932FEGMedicare ID - Type Unspecified
PAE64024Medicare UPIN