Provider Demographics
NPI:1922219492
Name:FARRIS, BRUCE M
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:M
Last Name:FARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:BRUCE
Other - Middle Name:M
Other - Last Name:FARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:301 EAST CALHOUN STREET
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098
Mailing Address - Country:US
Mailing Address - Phone:815-338-7774
Mailing Address - Fax:815-338-0701
Practice Address - Street 1:301 EAST CALHOUN STREET
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098
Practice Address - Country:US
Practice Address - Phone:815-338-7774
Practice Address - Fax:815-338-0701
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice