Healthcare Provider Details

I. General information

NPI: 1821103094
Provider Name (Legal Business Name): BRUCE ALLEN DANIEL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6822 E 1000 S
FT. DUCHESNE UT
84026
US

IV. Provider business mailing address

2675 W 1500 N
VERNAL UT
84078-9626
US

V. Phone/Fax

Practice location:
  • Phone: 435-722-5122
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number22877
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: