Provider Demographics
NPI:1104913516
Name:LUSTBADER, BRUCE ROBERT (DMD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ROBERT
Last Name:LUSTBADER
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:168 FRANKLIN CORNER RD
Mailing Address - Street 2:BLDG 2
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08648
Mailing Address - Country:US
Mailing Address - Phone:609-896-2400
Mailing Address - Fax:609-896-2401
Practice Address - Street 1:168 FRANKLIN CORNER RD
Practice Address - Street 2:BLDG 2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648
Practice Address - Country:US
Practice Address - Phone:609-896-2400
Practice Address - Fax:609-896-2401
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ117591223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics