Provider Demographics
NPI:1851686430
Name:SHAHEEN, BRUCE BRONDON (DDS)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:BRONDON
Last Name:SHAHEEN
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:#3 CR 6523
Mailing Address - Street 2:SUNDANCE DENTAL CARE OF KIRTLAND
Mailing Address - City:KIRTLAND
Mailing Address - State:NM
Mailing Address - Zip Code:87417
Mailing Address - Country:US
Mailing Address - Phone:505-598-6800
Mailing Address - Fax:505-598-6830
Practice Address - Street 1:#3 CR 6523
Practice Address - Street 2:SUNDANCE DENTAL CARE OF KIRTLAND
Practice Address - City:KIRTLAND
Practice Address - State:NM
Practice Address - Zip Code:87417
Practice Address - Country:US
Practice Address - Phone:505-598-6800
Practice Address - Fax:505-598-6830
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD 3503122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist