Provider Demographics
NPI:1316607757
Name:BRADLEY J CONVISSAR DMD PA
Entity type:Organization
Organization Name:BRADLEY J CONVISSAR DMD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:CONVISSAR
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:856-778-8655
Mailing Address - Street 1:2 RANCOCAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2057
Mailing Address - Country:US
Mailing Address - Phone:856-778-8655
Mailing Address - Fax:
Practice Address - Street 1:2 RANCOCAS BLVD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2057
Practice Address - Country:US
Practice Address - Phone:856-778-8655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental