Healthcare Provider Details

I. General information

NPI: 1992865604
Provider Name (Legal Business Name): BRUCE WAYNE OVERTON DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6037 HARBOUR PARK DRIVE
MIDLOTHIAN VA
23112
US

IV. Provider business mailing address

6037 HARBOUR PARK DRIVE
MIDLOTHIAN VA
23112
US

V. Phone/Fax

Practice location:
  • Phone: 804-744-3636
  • Fax: 804-744-6365
Mailing address:
  • Phone: 804-744-3636
  • Fax: 804-744-6365

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number0401007578
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: