Provider Demographics
NPI:1386725885
Name:STUMBAUGH, BRUCE RAY (DDS)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:RAY
Last Name:STUMBAUGH
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 1:122 W WOODLAWN ROAD SUITE A 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28217-2172
Mailing Address - Country:US
Mailing Address - Phone:704-525-8528
Mailing Address - Fax:704-525-9311
Practice Address - Street 1:122 W WOODLAWN ROAD SUITE A 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28217-2172
Practice Address - Country:US
Practice Address - Phone:704-525-8528
Practice Address - Fax:704-525-9311
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC37231223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC98185OtherBC BS
NCU48839Medicaid