=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366752495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUCE R. TREFZ, DDS, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/07/2010
-----------------------------------------------------
Last Update Date | 10/07/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1041 X-RAY DRIVE
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28034-7489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-861-1235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1041 X-RAY DRIVE
-----------------------------------------------------
City | GASTONIA
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28034-7489
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-861-1235
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. BRUCE ROBERT TREFZ
-----------------------------------------------------
Credential | ORAL SURGEON
-----------------------------------------------------
Telephone | 704-861-1235
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 4960
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------