Provider Demographics
NPI:1679601843
Name:PARKER, BRUCE DALE (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DALE
Last Name:PARKER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5891 BENNETTS CORNERS RD
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-8618
Mailing Address - Country:US
Mailing Address - Phone:315-672-5198
Mailing Address - Fax:
Practice Address - Street 1:5109 W GENESEE ST
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2352
Practice Address - Country:US
Practice Address - Phone:315-487-2825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0329421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice