Provider Demographics
NPI:1629274899
Name:VALENTINE, BRUCE (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:VALENTINE
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 1:1801 TULLY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-2931
Mailing Address - Country:US
Mailing Address - Phone:209-526-0982
Mailing Address - Fax:209-527-1971
Practice Address - Street 1:1801 TULLY RD
Practice Address - Street 2:SUITE B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-2931
Practice Address - Country:US
Practice Address - Phone:209-526-0982
Practice Address - Fax:209-527-1971
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20789OtherDENTAL LICENSE
CA236914OtherDENTI-CAL