Healthcare Provider Details

I. General information

NPI: 1508701830
Provider Name (Legal Business Name): DANIEL B BRUIN DMD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2026
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
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

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: DR. DANIEL BRADLEY BRUIN
Title or Position: OWNER
Credential: BRUIN
Phone: 941-468-5193