Provider Demographics
NPI:1699047167
Name:BRUCE R TRIPP JR DDS PA
Entity type:Organization
Organization Name:BRUCE R TRIPP JR DDS PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:RAY
Authorized Official - Last Name:TRIPP
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:252-752-7880
Mailing Address - Street 1:5076 US 264 E
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5804
Mailing Address - Country:US
Mailing Address - Phone:252-752-7880
Mailing Address - Fax:252-752-9602
Practice Address - Street 1:5076 US 264 E
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5804
Practice Address - Country:US
Practice Address - Phone:252-752-7880
Practice Address - Fax:252-752-9602
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-31
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5112122300000X
NC124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5919749Medicaid