Provider Demographics
NPI:1760450555
Name:DENNIS, BRUCE W (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:DENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 ARLINGTON CTR
Mailing Address - Street 2:PMB 224
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-2883
Mailing Address - Country:US
Mailing Address - Phone:580-272-0025
Mailing Address - Fax:580-272-6559
Practice Address - Street 1:721 BETTER NOW PLZ
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-2279
Practice Address - Country:US
Practice Address - Phone:580-272-0025
Practice Address - Fax:580-272-6559
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK18405207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK18405OtherMEDICAL LICENSE
OKBD3701528OtherDEA
OK200034380AMedicaid
OK241413209OtherMEDICARE
F73231Medicare UPIN
OK241413209Medicare PIN