Provider Demographics
NPI:1689792012
Name:LACOSTE, BRUCE ALAN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALAN
Last Name:LACOSTE
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 1:555 W COURT ST
Mailing Address - Street 2:SUITE #102
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3664
Mailing Address - Country:US
Mailing Address - Phone:815-932-3822
Mailing Address - Fax:815-937-3524
Practice Address - Street 1:555 W COURT ST
Practice Address - Street 2:SUITE #102
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3664
Practice Address - Country:US
Practice Address - Phone:815-932-3822
Practice Address - Fax:815-937-3524
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice