Provider Demographics
NPI:1083866248
Name:BULLOCK, JOHN A (DMD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:A
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29292 SW TOWN CENTER LOOP E
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9491
Mailing Address - Country:US
Mailing Address - Phone:503-682-0431
Mailing Address - Fax:503-682-3873
Practice Address - Street 1:29292 SW TOWN CENTER LOOP E
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9491
Practice Address - Country:US
Practice Address - Phone:503-682-0431
Practice Address - Fax:503-682-3873
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD73701223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice