Healthcare Provider Details

I. General information

NPI: 1669486049
Provider Name (Legal Business Name): BRUCE CHISHOLM BENNETT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 WEST ROLLINS RD
ROUND LAKE BEACH IL
60073
US

IV. Provider business mailing address

1443 NORTH WILLOW ST
LAKE FOREST IL
60045
US

V. Phone/Fax

Practice location:
  • Phone: 847-546-6644
  • Fax: 847-546-6645
Mailing address:
  • Phone: 847-234-3014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number15471
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: