Provider Demographics
NPI:1508983446
Name:GLASS, BRUCE WILLARD
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:WILLARD
Last Name:GLASS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 TREMBLEY LN
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-1224
Mailing Address - Country:US
Mailing Address - Phone:831-728-4695
Mailing Address - Fax:831-728-1719
Practice Address - Street 1:25 TREMBLEY LN
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076-1224
Practice Address - Country:US
Practice Address - Phone:831-728-4695
Practice Address - Fax:831-728-1719
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist