Healthcare Provider Details

I. General information

NPI: 1235104688
Provider Name (Legal Business Name): BRUCE SHINTARO ABE D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 09/25/2023
Certification Date: 09/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WASHINGTON ST STE 740
SAN DIEGO CA
92103-2231
US

IV. Provider business mailing address

501 WASHINGTON ST STE 740
SAN DIEGO CA
92103-2231
US

V. Phone/Fax

Practice location:
  • Phone: 619-393-7511
  • Fax:
Mailing address:
  • Phone: 619-417-9910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number47344
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: