Provider Demographics
NPI:1306039235
Name:CONDELLO, BRUCE ALAN (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:CONDELLO
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 1:5930 SOUTH 58TH STREET
Mailing Address - Street 2:SUITE E
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68516
Mailing Address - Country:US
Mailing Address - Phone:402-423-9040
Mailing Address - Fax:402-423-9048
Practice Address - Street 1:5930 SOUTH 58TH STREET
Practice Address - Street 2:SUITE E
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68516
Practice Address - Country:US
Practice Address - Phone:402-423-9040
Practice Address - Fax:402-423-9048
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE55651223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice