Basic Information
| Provider Information | |||||||||
| NPI: | 1013923010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | ALAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | II | ||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2864 ASHMUN STREET | ||||||||
| Address2: | |||||||||
| City: | SAULT SAINTE MARIE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066325260 | ||||||||
| FaxNumber: | 9066325276 | ||||||||
| Practice Location | |||||||||
| Address1: | 2864 ASHMUN STREET | ||||||||
| Address2: | SAULT TRIBAL HEALTH CENTER | ||||||||
| City: | SAULT STE MARIE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9066325200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 2901015521 | MI | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 2849111 | 05 | MI | MEDICAID |