Healthcare Provider Details

I. General information

NPI: 1992765671
Provider Name (Legal Business Name): ERIC GORDON BRUCE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1009 RIDGEWAY PL SUITE 100
FARMINGTON NM
87401-2092
US

IV. Provider business mailing address

602 AREDO DE CARLOS
FARMINGTON NM
87401-4063
US

V. Phone/Fax

Practice location:
  • Phone: 505-599-9359
  • Fax: 505-599-8177
Mailing address:
  • Phone: 505-326-1125
  • Fax: 505-599-8177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDD2066
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License NumberH-D-A-04821
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number4344
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: