Provider Demographics
NPI:1528166584
Name:HOWARD, BRUCE W (DMD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:W
Last Name:HOWARD
Suffix:
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 1:3311 HAMPTON XING
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-1604
Mailing Address - Country:US
Mailing Address - Phone:636-699-0579
Mailing Address - Fax:
Practice Address - Street 1:SOUTHSIDE DENTAL CARE
Practice Address - Street 2:3654 GRAVOIS AVE
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63116
Practice Address - Country:US
Practice Address - Phone:314-865-3838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2022-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO0143001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO402192017Medicaid