1073736096 NPI number — DR. BRUCE DANIEL STORM JR. DDS

Table of content: DR. BRUCE DANIEL STORM JR. DDS (NPI 1073736096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073736096 NPI number — DR. BRUCE DANIEL STORM JR. DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STORM
Provider First Name:
BRUCE
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
DDS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STORM
Provider Other First Name:
B
Provider Other Middle Name:
DAN
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1073736096
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
BOX 824
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73648-0824
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
580-225-1020
Provider Business Mailing Address Fax Number:
580-225-0707

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 N GARRETT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELK CITY
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
73644
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
580-225-1020
Provider Business Practice Location Address Fax Number:
580-225-0707
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  3782 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com