Provider Demographics
NPI:1174792022
Name:BLEIL, BRUCE THOMPSON (DMD)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:THOMPSON
Last Name:BLEIL
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12210 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-5603
Mailing Address - Country:US
Mailing Address - Phone:228-832-0089
Mailing Address - Fax:228-832-0089
Practice Address - Street 1:15465 OAK LANE, STE. 100 - H
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3524
Practice Address - Country:US
Practice Address - Phone:228-832-4450
Practice Address - Fax:228-832-4550
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-25
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1475-721223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01831829Medicaid