Provider Demographics
NPI:1346670627
Name:TABER, BRUCE LEE (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:LEE
Last Name:TABER
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 1:25835 BARTON RD.
Mailing Address - Street 2:STE 104
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-796-2299
Mailing Address - Fax:909-796-2509
Practice Address - Street 1:25835 BARTON RD.
Practice Address - Street 2:STE 104
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-796-2299
Practice Address - Fax:909-796-2509
Is Sole Proprietor?:No
Enumeration Date:2013-11-22
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34906122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1538368154OtherDENTIST