Provider Demographics
NPI:1679673834
Name:BULLOCK, JEREMY W (DMD)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:W
Last Name:BULLOCK
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 1:3744 BELT LINE RD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001-4301
Mailing Address - Country:US
Mailing Address - Phone:972-243-3948
Mailing Address - Fax:
Practice Address - Street 1:3744 BELT LINE RD
Practice Address - Street 2:
Practice Address - City:ADDISON
Practice Address - State:TX
Practice Address - Zip Code:75001-4301
Practice Address - Country:US
Practice Address - Phone:972-243-3948
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX24312122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
203306077Medicare UPIN