Provider Demographics
NPI:1639141021
Name:DECKLER, BRUCE LENID (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LENID
Last Name:DECKLER
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 1:11708 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND HILL
Mailing Address - State:NY
Mailing Address - Zip Code:11418-1743
Mailing Address - Country:US
Mailing Address - Phone:718-849-7983
Mailing Address - Fax:
Practice Address - Street 1:11708 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND HILL
Practice Address - State:NY
Practice Address - Zip Code:11418-1743
Practice Address - Country:US
Practice Address - Phone:718-849-7983
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042555-11223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01375548Medicaid