Provider Demographics
NPI:1275682544
Name:BLANCHARD, BRUCE ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:BLANCHARD
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 1:5501 WOODSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-2243
Mailing Address - Country:US
Mailing Address - Phone:843-449-5035
Mailing Address - Fax:
Practice Address - Street 1:5501 WOODSIDE AVE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-2243
Practice Address - Country:US
Practice Address - Phone:843-449-5035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2973122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCZA9831Medicaid