Provider Demographics
NPI:1104494061
Name:BRUCE, LYDIA JULIANNA (DDS)
Entity type:Individual
Prefix:
First Name:LYDIA
Middle Name:JULIANNA
Last Name:BRUCE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3944 N RUSHWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2427
Mailing Address - Country:US
Mailing Address - Phone:405-564-8849
Mailing Address - Fax:
Practice Address - Street 1:527 N GROVE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-4520
Practice Address - Country:US
Practice Address - Phone:316-262-2415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-16
Last Update Date:2021-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS61864122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist