Healthcare Provider Details

I. General information

NPI: 1982737797
Provider Name (Legal Business Name): BRUCE BENNINGER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4534 PRECISSI LN
STOCKTON CA
95207-6213
US

IV. Provider business mailing address

4534 PRECISSI LN
STOCKTON CA
95207-6213
US

V. Phone/Fax

Practice location:
  • Phone: 209-478-5167
  • Fax: 209-478-2313
Mailing address:
  • Phone: 209-478-5167
  • Fax: 209-478-2313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number17238
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: