Provider Demographics
NPI:1992765671
Name:BRUCE, ERIC GORDON (DDS)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:GORDON
Last Name:BRUCE
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 1:602 AREDO DE CARLOS
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-4063
Mailing Address - Country:US
Mailing Address - Phone:505-326-1125
Mailing Address - Fax:505-599-8177
Practice Address - Street 1:1009 RIDGEWAY PL
Practice Address - Street 2:SUITE 100
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-2092
Practice Address - Country:US
Practice Address - Phone:505-599-9359
Practice Address - Fax:505-599-8177
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMDD2066122300000X
COH-D-A-04821122300000X
OK4344122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM83327Medicaid