Provider Demographics
NPI:1194948943
Name:RENN, BRUCE J (DDS)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:J
Last Name:RENN
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 1:202 UNION ST
Mailing Address - Street 2:STE 3
Mailing Address - City:TITUSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16354
Mailing Address - Country:US
Mailing Address - Phone:814-827-6714
Mailing Address - Fax:814-827-2706
Practice Address - Street 1:202 UNION ST
Practice Address - Street 2:STE 3
Practice Address - City:TITUSVILLE
Practice Address - State:PA
Practice Address - Zip Code:16354
Practice Address - Country:US
Practice Address - Phone:814-827-6714
Practice Address - Fax:814-827-2706
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADS02011561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0005205570001Medicaid