Provider Demographics
NPI:1750512174
Name:JANZEN, BRUCE DAVID
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:DAVID
Last Name:JANZEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12190 2ND STREET
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399
Mailing Address - Country:US
Mailing Address - Phone:909-797-9099
Mailing Address - Fax:909-797-7794
Practice Address - Street 1:11750 CHOLLA DR STE B
Practice Address - Street 2:
Practice Address - City:DESERT HOT SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92240-3064
Practice Address - Country:US
Practice Address - Phone:760-251-0044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-03
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA#39422122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist