Provider Demographics
NPI:1891134896
Name:HAGGERTY, BRUCE JR (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:HAGGERTY
Suffix:JR
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 1:4316 HILLINGDON BND
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23321-2458
Mailing Address - Country:US
Mailing Address - Phone:214-991-5166
Mailing Address - Fax:
Practice Address - Street 1:4072 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23701-2820
Practice Address - Country:US
Practice Address - Phone:757-337-4261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-23
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX28897122300000X
VA04014151991223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist