Provider Demographics
NPI:1790073609
Name:ABBOTT, BRUCE ALAN (DDS, PHARMD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:ABBOTT
Suffix:
Gender:M
Credentials:DDS, PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10TH MEDICAL GROUP
Mailing Address - Street 2:4102 PINION DRIVE
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10TH MEDICAL GROUP
Practice Address - Street 2:4102 PINION DRIVE
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840
Practice Address - Country:US
Practice Address - Phone:540-850-3590
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-12
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1111111111183500000X
FLDN27904122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No183500000XPharmacy Service ProvidersPharmacist