Healthcare Provider Details

I. General information

NPI: 1770754921
Provider Name (Legal Business Name): BRUCE A BEVERSDORF DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2008
Last Update Date: 03/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S CHERRY ST
WITTENBERG WI
54499
US

IV. Provider business mailing address

PO BOX H
WITTENBERG WI
54499
US

V. Phone/Fax

Practice location:
  • Phone: 715-253-2694
  • Fax: 715-253-3838
Mailing address:
  • Phone: 715-253-2694
  • Fax: 715-253-3838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number5002135
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: