Healthcare Provider Details

I. General information

NPI: 1619557048
Provider Name (Legal Business Name): LUKE BJORKLUND
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2021
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 GROVE ST
EAGLE WI
53119-2249
US

IV. Provider business mailing address

630 N VEL R PHILLIPS AVE UNIT 619
MILWAUKEE WI
53203-2809
US

V. Phone/Fax

Practice location:
  • Phone: 262-594-2223
  • Fax:
Mailing address:
  • Phone: 608-963-6219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number1002544-15
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: