Provider Demographics
NPI:1982737797
Name:BENNINGER, BRUCE (DDS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:BENNINGER
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 1:4534 PRECISSI LN
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6213
Mailing Address - Country:US
Mailing Address - Phone:209-478-5167
Mailing Address - Fax:209-478-2313
Practice Address - Street 1:4534 PRECISSI LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-6213
Practice Address - Country:US
Practice Address - Phone:209-478-5167
Practice Address - Fax:209-478-2313
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172381223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA94 2L88487OtherTAX ID