Provider Demographics
NPI:1790978682
Name:LOOSLI, BRUCE PARK (DMD)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:PARK
Last Name:LOOSLI
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3060 S REDWOOD RD
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84119-3058
Mailing Address - Country:US
Mailing Address - Phone:801-972-0555
Mailing Address - Fax:801-972-0920
Practice Address - Street 1:3060 S REDWOOD RD
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84119-3058
Practice Address - Country:US
Practice Address - Phone:801-972-0555
Practice Address - Fax:801-972-0920
Is Sole Proprietor?:No
Enumeration Date:2007-08-23
Last Update Date:2007-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT145173-9922122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist