MEDICARE: BRUCE S. WARDELL DMD, PC

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	021.002325	IL

General Provider Information

NPI Number	:	1427443399
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUCE S. WARDELL DMD, PC

Provider Business Mailing Address
First Line	:	1000 GRAND CANYON PKWY
Second Line	:	SUITE 305
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1705
Country	:	US
Telephone Number	:	847-884-0250
Fax Number	:	847-884-1967

Provider Business Practice Location Address
First Line	:	1000 GRAND CANYON PKWY
Second Line	:	SUITE 305
City	:	HOFFMAN ESTATES
State	:	IL
Zip	:	60169-1705
Country	:	US
Telephone Number	:	847-884-0250
Fax Number	:	847-884-1967

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. BRUCE S WARDELL
Credential	:	D.M.D.
Telephone Number	:	630-697-0334

Provider Enumeration Date	:	03/30/2015
Last Update Date	:	03/30/2015

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