Provider Demographics
NPI:1134497639
Name:BULLOCK, JOSEPH ROBERT (DDS)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:ROBERT
Last Name:BULLOCK
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 1:2825 NE WEST DEVILS LAKE RD
Mailing Address - Street 2:
Mailing Address - City:LINCOLN CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97367-5128
Mailing Address - Country:US
Mailing Address - Phone:541-994-3033
Mailing Address - Fax:541-994-6489
Practice Address - Street 1:2825 NE WEST DEVILS LAKE RD
Practice Address - Street 2:
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-5128
Practice Address - Country:US
Practice Address - Phone:541-994-3033
Practice Address - Fax:541-994-6489
Is Sole Proprietor?:No
Enumeration Date:2011-12-12
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORD5918122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist