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General NPI Number Information
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NPI Number | 1730197468
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Entity Type | Organization
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Legal Business Name | CRYSTAL LAKE ORAL MAXILLOFACIAL SURGERY LTD
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Dates
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Enumeration Date | 08/05/2006
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Last Update Date | 06/03/2010
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Provider Practice Location Address
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Address Line | 690 N IL ROUTE 31
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City | CRYSTAL LAKE
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State | IL
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Zip | 60012-3790
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Country | US
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Telephone | 815-459-5600
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Fax | 815-459-5615
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Provider Business Mailing Address
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Address Line | 690 N IL ROUTE 31
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City | CRYSTAL LAKE
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State | IL
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Zip | 60012-3790
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Country | US
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Telephone | 815-459-5600
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Fax | 815-459-5615
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Authorized Official
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Title or Position | VICE-PRESIDENT
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Name | DR. KURT E BRUKSCH
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Credential | D.D.S.
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Telephone | 815-459-5600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 019018137
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License Number State | IL
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