Provider Demographics
NPI:1053530733
Name:SUNNYSIDE FAMILY DENTAL
Entity type:Organization
Organization Name:SUNNYSIDE FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OZREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BUNTAK
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-272-4900
Mailing Address - Street 1:381 ANGELL ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3214
Mailing Address - Country:US
Mailing Address - Phone:401-272-4900
Mailing Address - Fax:401-272-5989
Practice Address - Street 1:381 ANGELL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02906-3214
Practice Address - Country:US
Practice Address - Phone:401-272-4900
Practice Address - Fax:401-272-5989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDEN02762122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty