Provider Demographics
NPI:1851730923
Name:BRUIN, DANIEL BRADLEY (DMD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BRADLEY
Last Name:BRUIN
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 1:6958 NEBRASKA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEONARD WOOD
Mailing Address - State:MO
Mailing Address - Zip Code:65473-1618
Mailing Address - Country:US
Mailing Address - Phone:573-596-3606
Mailing Address - Fax:
Practice Address - Street 1:6958 NEBRASKA AVE
Practice Address - Street 2:
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-1618
Practice Address - Country:US
Practice Address - Phone:573-596-3038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2021-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDN20166122300000X, 1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics
No122300000XDental ProvidersDentist