Healthcare Provider Details

I. General information

NPI: 1629376009
Provider Name (Legal Business Name): BRUCE JAY ETKIN DDS, CAGS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 03/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7181 E CAMELBACK RD APT 1201
SCOTTSDALE AZ
85251-1279
US

IV. Provider business mailing address

7181 E CAMELBACK RD APT 1201
SCOTTSDALE AZ
85251-1279
US

V. Phone/Fax

Practice location:
  • Phone: 480-223-8990
  • Fax: 480-991-2474
Mailing address:
  • Phone: 480-223-8990
  • Fax: 480-991-2474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number2188
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: