Provider Demographics
NPI:1891816476
Name:JACK, BRUCE ALEXANDER (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALEXANDER
Last Name:JACK
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 1:7416 SULKY DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-6804
Mailing Address - Country:US
Mailing Address - Phone:505-730-3355
Mailing Address - Fax:
Practice Address - Street 1:3309 JUAN TABO BLVD NE
Practice Address - Street 2:SUITE B
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87111-5131
Practice Address - Country:US
Practice Address - Phone:505-730-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM14411223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice