MEDICARE: MR. BRUCE W HULTGREN DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry	8152	MN

General Provider Information

NPI Number	:	1073534632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRUCE W HULTGREN DDS

Provider Business Mailing Address
First Line	:	7825 TERREY PINE COURT
Second Line	:	SUITE 101
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55347
Country	:	US
Telephone Number	:	952-937-0111
Fax Number	:	952-937-1492

Provider Business Practice Location Address
First Line	:	7825 TERREY PINE COURT
Second Line	:	SUITE 101
City	:	EDEN PRAIRIE
State	:	MN
Zip	:	55347
Country	:	US
Telephone Number	:	952-937-0111
Fax Number	:	952-937-1492

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/21/2006
Last Update Date	:	07/08/2007

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