MEDICARE: DR. BRUCE H COLLIGNON DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	12256	MO

General Provider Information

NPI Number	:	1811984560
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRUCE H COLLIGNON DDS

Provider Business Mailing Address
First Line	:	7214 EXECUTIVE PKWY
Second Line	:
City	:	HOUSE SPRINGS
State	:	MO
Zip	:	63051-2981
Country	:	US
Telephone Number	:	636-671-0102
Fax Number	:	636-671-1575

Provider Business Practice Location Address
First Line	:	7214 EXECUTIVE PKWY
Second Line	:
City	:	HOUSE SPRINGS
State	:	MO
Zip	:	63051-2981
Country	:	US
Telephone Number	:	636-671-0102
Fax Number	:	636-671-1575

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2005
Last Update Date	:	07/08/2007

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