Provider Demographics
NPI:1073736096
Name:STORM, BRUCE DANIEL JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DANIEL
Last Name:STORM
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:B
Other - Middle Name:DAN
Other - Last Name:STORM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:BOX 824
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73648-0824
Mailing Address - Country:US
Mailing Address - Phone:580-225-1020
Mailing Address - Fax:580-225-0707
Practice Address - Street 1:300 N GARRETT
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644
Practice Address - Country:US
Practice Address - Phone:580-225-1020
Practice Address - Fax:580-225-0707
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3782122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist