Provider Demographics
NPI:1457601759
Name:GARRETT, BRUCE WARREN (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:WARREN
Last Name:GARRETT
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 1:626 SUMMIT
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265
Mailing Address - Country:US
Mailing Address - Phone:573-581-3121
Mailing Address - Fax:
Practice Address - Street 1:626 SUMMIT
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265
Practice Address - Country:US
Practice Address - Phone:573-581-3121
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO012079122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist