Healthcare Provider Details

I. General information

NPI: 1073534632
Provider Name (Legal Business Name): BRUCE W HULTGREN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7825 TERREY PINE COURT SUITE 101
EDEN PRAIRIE MN
55347
US

IV. Provider business mailing address

7825 TERREY PINE COURT SUITE 101
EDEN PRAIRIE MN
55347
US

V. Phone/Fax

Practice location:
  • Phone: 952-937-0111
  • Fax: 952-937-1492
Mailing address:
  • Phone: 952-937-0111
  • Fax: 952-937-1492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number8152
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: