Provider Demographics
NPI:1265583066
Name:GASTON, BRUCE A (DDS)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:GASTON
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 1:1911 MALVERN AVE.
Mailing Address - Street 2:SUITE A
Mailing Address - City:HOT SPRINGS
Mailing Address - State:AR
Mailing Address - Zip Code:71901
Mailing Address - Country:US
Mailing Address - Phone:501-609-9196
Mailing Address - Fax:501-609-9148
Practice Address - Street 1:1911 MALVERN AVE.
Practice Address - Street 2:SUITE A
Practice Address - City:HOT SPRINGS
Practice Address - State:AR
Practice Address - Zip Code:71901
Practice Address - Country:US
Practice Address - Phone:501-609-9196
Practice Address - Fax:501-609-9148
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR191223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145594608Medicaid
AR961464OtherUNITED CONCORDIA
AR5X168OtherBLUE CROSS BLUE SHIELD