Provider Demographics
NPI:1689793804
Name:BAINES, BRUCE IVAN (DENTIST)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:IVAN
Last Name:BAINES
Suffix:
Gender:M
Credentials:DENTIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 DEMAREST CT
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-1904
Mailing Address - Country:US
Mailing Address - Phone:201-567-4999
Mailing Address - Fax:
Practice Address - Street 1:386 CENTRAL AVE.
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307
Practice Address - Country:US
Practice Address - Phone:201-659-5030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ22DI008771001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ22DI00877100OtherDENTIST