Provider Demographics
NPI:1639585821
Name:BRUCE, JESSICA DOMINIQUE (DMD)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:DOMINIQUE
Last Name:BRUCE
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 BOKUM RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06412-1339
Mailing Address - Country:US
Mailing Address - Phone:860-559-9146
Mailing Address - Fax:
Practice Address - Street 1:29 BOKUM RD
Practice Address - Street 2:
Practice Address - City:CHESTER
Practice Address - State:CT
Practice Address - Zip Code:06412-1339
Practice Address - Country:US
Practice Address - Phone:860-559-9146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-08
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2.011701122300000X
CT117011223P0221X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No122300000XDental ProvidersDentist
No1223P0221XDental ProvidersDentistPediatric Dentistry