Provider Demographics
NPI:1649401423
Name:KANEHL, BRUCE ARTHUR (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ARTHUR
Last Name:KANEHL
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 1:7933 BAYMEADOWS WAY
Mailing Address - Street 2:SUITE 5
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-7564
Mailing Address - Country:US
Mailing Address - Phone:904-731-2162
Mailing Address - Fax:904-448-1403
Practice Address - Street 1:7933 BAYMEADOWS WAY
Practice Address - Street 2:SUITE 5
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-7564
Practice Address - Country:US
Practice Address - Phone:904-731-2162
Practice Address - Fax:904-448-1403
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN 68541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
6368260001Medicare NSC