Healthcare Provider Details

I. General information

NPI: 1740392232
Provider Name (Legal Business Name): BRUCE E SMITH BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 CAMP MOWEEN RD
LEBANON CT
06249-2704
US

IV. Provider business mailing address

99 CAMP MOWEEN RD
LEBANON CT
06249-2704
US

V. Phone/Fax

Practice location:
  • Phone: 860-859-0824
  • Fax: 869-859-0824
Mailing address:
  • Phone: 860-859-0824
  • Fax: 869-859-0824

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number000378
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: