Provider Demographics
NPI:1942429311
Name:BRUCE, MARK ALLEN
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALLEN
Last Name:BRUCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 N VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IL
Mailing Address - Zip Code:62959-2335
Mailing Address - Country:US
Mailing Address - Phone:618-993-3187
Mailing Address - Fax:
Practice Address - Street 1:301 N VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-2335
Practice Address - Country:US
Practice Address - Phone:618-993-3187
Practice Address - Fax:618-993-0397
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL19-024396122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist