Provider Demographics
NPI:1700296605
Name:BRUCE S. DODGE, D.M.D., INC.
Entity Type:Organization
Organization Name:BRUCE S. DODGE, D.M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:S
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-846-9041
Mailing Address - Street 1:2800 W MAGNOLIA BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-3036
Mailing Address - Country:US
Mailing Address - Phone:818-846-9041
Mailing Address - Fax:818-842-4065
Practice Address - Street 1:2800 W MAGNOLIA BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-3036
Practice Address - Country:US
Practice Address - Phone:818-846-9041
Practice Address - Fax:818-842-4065
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-30
Last Update Date:2014-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284361223G0001X
CA294851223G0001X
CA417911223G0001X
CA450141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty