Provider Demographics
NPI:1821103094
Name:DANIEL, BRUCE ALLEN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:DANIEL
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 1:2675 W 1500 N
Mailing Address - Street 2:
Mailing Address - City:VERNAL
Mailing Address - State:UT
Mailing Address - Zip Code:84078-9626
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6822 E 1000 S
Practice Address - Street 2:
Practice Address - City:FT. DUCHESNE
Practice Address - State:UT
Practice Address - Zip Code:84026
Practice Address - Country:US
Practice Address - Phone:435-722-5122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA228771223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA22877OtherDDS