Provider Demographics
NPI:1902979362
Name:CHUBAK, BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:CHUBAK
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1803
Mailing Address - Country:US
Mailing Address - Phone:516-374-1745
Mailing Address - Fax:516-374-5161
Practice Address - Street 1:77 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1803
Practice Address - Country:US
Practice Address - Phone:516-374-1745
Practice Address - Fax:516-374-5161
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2011-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY33084122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00286526Medicaid