Provider Demographics
NPI:1679655757
Name:BULLARD, ROY HARRELL (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROY
Middle Name:HARRELL
Last Name:BULLARD
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 1:125 COLISEUM BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36109-2707
Mailing Address - Country:US
Mailing Address - Phone:334-272-0110
Mailing Address - Fax:334-272-3178
Practice Address - Street 1:125 COLISEUM BLVD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36109-2707
Practice Address - Country:US
Practice Address - Phone:334-272-0110
Practice Address - Fax:334-272-3178
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL41461223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL92549OtherBCBS PROVIDER NUMBER