Provider Demographics
NPI:1891737599
Name:BRAGDON, BRUCE R (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:BRAGDON
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 1:10 MATHES TER
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03824-2302
Mailing Address - Country:US
Mailing Address - Phone:603-868-5129
Mailing Address - Fax:
Practice Address - Street 1:10 MATHES TER
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NH
Practice Address - Zip Code:03824-2302
Practice Address - Country:US
Practice Address - Phone:603-868-5129
Practice Address - Fax:603-868-5142
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH89191854Medicaid