Provider Demographics
NPI:1700079852
Name:PELLER, BRUCE G (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:G
Last Name:PELLER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7842 N POINT BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27106-3234
Mailing Address - Country:US
Mailing Address - Phone:336-759-0651
Mailing Address - Fax:336-759-7454
Practice Address - Street 1:7842 N POINT BLVD STE B
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27106-3234
Practice Address - Country:US
Practice Address - Phone:336-759-0651
Practice Address - Fax:336-759-7454
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC45811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice