Healthcare Provider Details

I. General information

NPI: 1851730923
Provider Name (Legal Business Name): DANIEL BRADLEY BRUIN DMD MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2013
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 MARTIN SPRINGS DR STE A
ROLLA MO
65401-2978
US

IV. Provider business mailing address

6958 NEBRASKA AVE
FORT LEONARD WOOD MO
65473-1618
US

V. Phone/Fax

Practice location:
  • Phone: 941-468-5193
  • Fax:
Mailing address:
  • Phone: 573-596-3606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberDN20166
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number2023018477
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License NumberDN20166
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: