Provider Demographics
NPI:1013033414
Name:SCHRADER, BRUCE ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:SCHRADER
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 1:3305 81ST ST
Mailing Address - Street 2:STE D
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-2042
Mailing Address - Country:US
Mailing Address - Phone:806-745-8413
Mailing Address - Fax:
Practice Address - Street 1:3305 81ST ST
Practice Address - Street 2:STE D
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79423-2042
Practice Address - Country:US
Practice Address - Phone:806-745-8413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX168741223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX019049801Medicaid