Healthcare Provider Details

I. General information

NPI: 1568683142
Provider Name (Legal Business Name): BRUCE HAVENS D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 10/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7429 N 1ST ST STE 101
FRESNO CA
93720-2852
US

IV. Provider business mailing address

7429 N 1ST ST STE 101
FRESNO CA
93720-2852
US

V. Phone/Fax

Practice location:
  • Phone: 559-448-9870
  • Fax: 559-448-9870
Mailing address:
  • Phone: 559-448-9870
  • Fax: 559-448-9870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number46188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: