MEDICARE: DR. BRUCE W LILLY DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	31310	CA

General Provider Information

NPI Number	:	1548362197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE W LILLY DDS

Provider Business Mailing Address
First Line	:	303 S GLENOAKS BLVD
Second Line	:	SUITE 12
City	:	BURBANK
State	:	CA
Zip	:	91502-1319
Country	:	US
Telephone Number	:	818-846-2854
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 S GLENOAKS BLVD
Second Line	:	SUITE 12
City	:	BURBANK
State	:	CA
Zip	:	91502-1319
Country	:	US
Telephone Number	:	818-846-2854
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2006
Last Update Date	:	07/08/2007

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