Provider Demographics
NPI:1710982509
Name:WEITZ, BRUCE A (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:WEITZ
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 1:1700 COOPER FOSTER PARK RD W
Mailing Address - Street 2:#B
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-3679
Mailing Address - Country:US
Mailing Address - Phone:440-282-1396
Mailing Address - Fax:440-282-1790
Practice Address - Street 1:1700 COOPER FOSTER PARK RD W
Practice Address - Street 2:#B
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-3679
Practice Address - Country:US
Practice Address - Phone:440-282-1396
Practice Address - Fax:440-282-1790
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2014-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH300161261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0872908Medicare ID - Type UnspecifiedDENTAL WELFARE