Provider Demographics
NPI:1740392232
Name:SMITH, BRUCE E (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:E
Last Name:SMITH
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:99 CAMP MOWEEN RD
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:CT
Mailing Address - Zip Code:06249-2704
Mailing Address - Country:US
Mailing Address - Phone:860-859-0824
Mailing Address - Fax:869-859-0824
Practice Address - Street 1:99 CAMP MOWEEN RD
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:CT
Practice Address - Zip Code:06249-2704
Practice Address - Country:US
Practice Address - Phone:860-859-0824
Practice Address - Fax:869-859-0824
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000378237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00424577Medicaid
CT12DME0884CT01OtherANTHEM BC/BS