MEDICARE: DR. DWANE RICHARD BRUICK DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	12008370	IN

General Provider Information

NPI Number	:	1740255991
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DWANE RICHARD BRUICK DDS

Provider Business Mailing Address
First Line	:	6405 GEORGETOWN NORTH BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7007
Country	:	US
Telephone Number	:	260-485-0583
Fax Number	:	260-485-8029

Provider Business Practice Location Address
First Line	:	6405 GEORGETOWN NORTH BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46815-7007
Country	:	US
Telephone Number	:	260-485-0583
Fax Number	:	260-485-8029

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/21/2006
Last Update Date	:	07/08/2007

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