Provider Demographics
NPI:1275546970
Name:BRIDGES, III, GEORGE I TRACE (DDS)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:I TRACE
Last Name:BRIDGES, III
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 1:8235 NW STONEBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-4127
Mailing Address - Country:US
Mailing Address - Phone:580-591-1641
Mailing Address - Fax:
Practice Address - Street 1:2928 NW CACHE RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505-3827
Practice Address - Country:US
Practice Address - Phone:580-355-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA860044OtherUNITED CONCORDIA
OK203345893001OtherBLUE CROSS/BLUE SHIELD