Provider Demographics
NPI:1306902382
Name:RIDDLE, BRUCE CLAYTON (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CLAYTON
Last Name:RIDDLE
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:PO BOX 1129
Mailing Address - Street 2:150 VETERANS BLVD
Mailing Address - City:BRYSON CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28713
Mailing Address - Country:US
Mailing Address - Phone:828-488-2211
Mailing Address - Fax:828-488-8237
Practice Address - Street 1:150 VETERANS BLVD
Practice Address - Street 2:
Practice Address - City:BRYSON CITY
Practice Address - State:NC
Practice Address - Zip Code:28713
Practice Address - Country:US
Practice Address - Phone:828-488-2211
Practice Address - Fax:828-488-8237
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6719122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8990031Medicaid
NC90031OtherBCBS
U66768Medicare UPIN