Provider Demographics
NPI:1164521043
Name:VANDE BERG, BRUCE ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:VANDE BERG
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 1:1010 HIGH HOUSE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27513-3576
Mailing Address - Country:US
Mailing Address - Phone:919-461-0110
Mailing Address - Fax:919-461-0114
Practice Address - Street 1:1010 HIGH HOUSE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27513-3576
Practice Address - Country:US
Practice Address - Phone:919-461-0110
Practice Address - Fax:919-461-0114
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6408122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
112637OtherUNITED CONCORDIA
218581OtherCIGNA
98762OtherBCBS
5846074OtherAETNA
112637OtherUNITED CONCORDIA
218581OtherCIGNA