Healthcare Provider Details

I. General information

NPI: 1053486696
Provider Name (Legal Business Name): ROBERT BRUCE MACY DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 FULTON AVE
COOS BAY OR
97420-2895
US

IV. Provider business mailing address

1310 INGERSOLL ST
COOS BAY OR
97420-1233
US

V. Phone/Fax

Practice location:
  • Phone: 541-888-6433
  • Fax: 541-888-7505
Mailing address:
  • Phone: 541-267-2525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberD3567
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: