Healthcare Provider Details

I. General information

NPI: 1740339902
Provider Name (Legal Business Name): BRUCE EDISON BENTLEY JR. D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 LEANDER RD
GEORGETOWN TX
78628-8707
US

IV. Provider business mailing address

1229 LEANDER RD
GEORGETOWN TX
78628-8707
US

V. Phone/Fax

Practice location:
  • Phone: 434-841-4251
  • Fax: 512-688-5073
Mailing address:
  • Phone: 512-872-4200
  • Fax: 512-688-5073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number0401006597
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30666
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: