Healthcare Provider Details

I. General information

NPI: 1356537310
Provider Name (Legal Business Name): BRUCE ROBERT MACDONALD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2007
Last Update Date: 09/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 CALUMET ST
LAKE LINDEN MI
49945-1309
US

IV. Provider business mailing address

207 CALUMET ST
LAKE LINDEN MI
49945-1309
US

V. Phone/Fax

Practice location:
  • Phone: 906-296-0886
  • Fax:
Mailing address:
  • Phone: 906-296-0886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number11326
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: