Provider Demographics
NPI:1821076662
Name:YODER, BRUCE LEE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEE
Last Name:YODER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9033 GENESIS LN SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9742
Mailing Address - Country:US
Mailing Address - Phone:360-895-4181
Mailing Address - Fax:360-895-4326
Practice Address - Street 1:1880 POTTERY AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-2518
Practice Address - Country:US
Practice Address - Phone:360-895-4321
Practice Address - Fax:360-895-4326
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA59751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5025796Medicaid
WA5975OtherWASHINGTON DENTAL SERVICE