Healthcare Provider Details

I. General information

NPI: 1053532440
Provider Name (Legal Business Name): JONATHAN BRUCE VANE D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 STATE ST
WARREN RI
02885-3128
US

IV. Provider business mailing address

38 STATE ST
WARREN RI
02885-3128
US

V. Phone/Fax

Practice location:
  • Phone: 401-245-6131
  • Fax: 401-245-5152
Mailing address:
  • Phone: 401-245-6131
  • Fax: 401-245-5152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDEN02726
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: