Provider Demographics
NPI:1043310113
Name:CARLYON, BRUCE R (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:CARLYON
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 1:1106 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:ESCANABA
Mailing Address - State:MI
Mailing Address - Zip Code:49829-3411
Mailing Address - Country:US
Mailing Address - Phone:906-786-3891
Mailing Address - Fax:906-786-3829
Practice Address - Street 1:1106 1ST AVE S
Practice Address - Street 2:
Practice Address - City:ESCANABA
Practice Address - State:MI
Practice Address - Zip Code:49829-3411
Practice Address - Country:US
Practice Address - Phone:906-786-3891
Practice Address - Fax:906-786-3829
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI120081223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4047589Medicaid