Basic Information
| Provider Information | |||||||||
| NPI: | 1073996765 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRUCE | ||||||||
| FirstName: | ANNA | ||||||||
| MiddleName: | CATHERINE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DMD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24116 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392254116 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018257280 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Practice Location | |||||||||
| Address1: | 215 HIGHWAY 51 N | ||||||||
| Address2: | |||||||||
| City: | BROOKHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6018231710 | ||||||||
| FaxNumber: | 6018258130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2015 | ||||||||
| LastUpdateDate: | 07/04/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 3815-15 | MS | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 08206565 | 05 | MS | MEDICAID |