Provider Demographics
NPI:1528072923
Name:BRUCE, JOHN M III (DMD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:M
Last Name:BRUCE
Suffix:III
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1744 N MITCHELL
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704
Mailing Address - Country:US
Mailing Address - Phone:208-322-1263
Mailing Address - Fax:208-322-5662
Practice Address - Street 1:1744 N MITCHELL
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704
Practice Address - Country:US
Practice Address - Phone:208-322-1263
Practice Address - Fax:208-322-5662
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD1770122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
143053OtherUNITED CONCORDIA
ID40144OtherBLUE SHIELD
ID68387OtherBLUE CROSS
ID0022165Medicaid