Healthcare Provider Details

I. General information

NPI: 1104942432
Provider Name (Legal Business Name): BRUCE F ANDREKUS, DDS,SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3726 ROOSEVELT RD
KENOSHA WI
53142-1900
US

IV. Provider business mailing address

3726 ROOSEVELT RD
KENOSHA WI
53142-1900
US

V. Phone/Fax

Practice location:
  • Phone: 262-652-7956
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number3650
License Number StateWI

VIII. Authorized Official

Name: BRUCE ANDREKUS
Title or Position: PRESIDENT
Credential: DDS
Phone: 262-652-7956