Basic Information
Provider Information | |||||||||
NPI: | 1790758860 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | STEWART | ||||||||
FirstName: | BRUCE | ||||||||
MiddleName: | E. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.D.S. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1010 MAIN ST S | ||||||||
Address2: |   | ||||||||
City: | MC KEE | ||||||||
State: | KY | ||||||||
PostalCode: | 404477089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8596267700 | ||||||||
FaxNumber: | 8596267890 | ||||||||
Practice Location | |||||||||
Address1: | 1010 MAIN ST S | ||||||||
Address2: |   | ||||||||
City: | MC KEE | ||||||||
State: | KY | ||||||||
PostalCode: | 404477089 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6062877104 | ||||||||
FaxNumber: | 6062873323 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/09/2006 | ||||||||
LastUpdateDate: | 03/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 13831 | MI | N |   | Dental Providers | Dentist | General Practice | 1223G0001X | D07912 | AZ | N |   | Dental Providers | Dentist | General Practice | 1223G0001X | 9269 | KY | Y |   | Dental Providers | Dentist | General Practice |
No ID Information.