Provider Demographics
NPI:1306856521
Name:DODGE, BRUCE STEVEN (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:STEVEN
Last Name:DODGE
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 ALTA PARK LANE
Mailing Address - Street 2:
Mailing Address - City:LA CANADA
Mailing Address - State:CA
Mailing Address - Zip Code:91011
Mailing Address - Country:US
Mailing Address - Phone:818-624-9074
Mailing Address - Fax:818-842-4065
Practice Address - Street 1:2800 W MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-3036
Practice Address - Country:US
Practice Address - Phone:818-846-9041
Practice Address - Fax:818-842-4065
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953536282OtherTAX IDENTIFICATION NUMBER