MEDICARE: BRUCE WM. THACKREY DMD

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	1223G0001X	General Practice Dentistry	19A15719	IL

General Provider Information

NPI Number	:	1518914340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRUCE WM. THACKREY DMD

Provider Business Mailing Address
First Line	:	1704 JEFFERSON AVE
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-4331
Country	:	US
Telephone Number	:	618-244-2440
Fax Number	:	618-244-0607

Provider Business Practice Location Address
First Line	:	1704 JEFFERSON AVE
Second Line	:
City	:	MOUNT VERNON
State	:	IL
Zip	:	62864-4331
Country	:	US
Telephone Number	:	618-244-2440
Fax Number	:	618-244-0607

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

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	07/08/2007

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