Provider Demographics
NPI:1528152451
Name:DERR, BRUCE JAMES (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:JAMES
Last Name:DERR
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 1:1420 NW VIVION RD
Mailing Address - Street 2:STE.#107
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64118-4555
Mailing Address - Country:US
Mailing Address - Phone:816-505-0555
Mailing Address - Fax:816-505-2662
Practice Address - Street 1:1420 NW VIVION RD
Practice Address - Street 2:STE.#107
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64118-4555
Practice Address - Country:US
Practice Address - Phone:816-505-0555
Practice Address - Fax:816-505-2662
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0121891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice