Provider Demographics
NPI:1013923010
Name:ANDERSON, BRUCE ALAN II (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:ANDERSON
Suffix:II
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 1:2864 ASHMUN STREET
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783
Mailing Address - Country:US
Mailing Address - Phone:906-632-5260
Mailing Address - Fax:906-632-5276
Practice Address - Street 1:2864 ASHMUN STREET
Practice Address - Street 2:SAULT TRIBAL HEALTH CENTER
Practice Address - City:SAULT STE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783
Practice Address - Country:US
Practice Address - Phone:906-632-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI29010155211223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2849111Medicaid
MI2849111Medicaid