Provider Demographics
NPI:1184689069
Name:MAXWELL, BRUCE CRAIG (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:CRAIG
Last Name:MAXWELL
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 1:747 W BROADWAY ST
Mailing Address - Street 2:PO BOX 330
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-2368
Mailing Address - Country:US
Mailing Address - Phone:417-256-2525
Mailing Address - Fax:417-256-7546
Practice Address - Street 1:747 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2368
Practice Address - Country:US
Practice Address - Phone:417-256-2525
Practice Address - Fax:417-256-7546
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2006000187122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO405408501Medicaid
MO407595800Medicaid