Provider Demographics
NPI:1417911975
Name:HORSWELL, BRUCE BRIAN (MD, DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:BRIAN
Last Name:HORSWELL
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:830 PENNSYLVANIA AVE 302
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25302-3390
Mailing Address - Country:US
Mailing Address - Phone:304-388-2950
Mailing Address - Fax:304-388-2951
Practice Address - Street 1:830 PENNSYLVANIA AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25302-3302
Practice Address - Country:US
Practice Address - Phone:304-388-2950
Practice Address - Fax:304-388-2951
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20528204E00000X
WV34831223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
No1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
190009986OtherRAILROAD MEDICARE
WV4002072000Medicaid
WV3002311000Medicaid
HO4050761Medicare PIN
HO4050762Medicare PIN
WV3002311000Medicaid
WV4002072000Medicaid