Provider Demographics
NPI:1154339448
Name:BRUKSCH, KURT (DDS)
Entity type:Individual
Prefix:DR
First Name:KURT
Middle Name:
Last Name:BRUKSCH
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 NORTH ROUTE #31
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60012
Mailing Address - Country:US
Mailing Address - Phone:815-459-5600
Mailing Address - Fax:815-459-5601
Practice Address - Street 1:690 NORTH ROUTE #31
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60012
Practice Address - Country:US
Practice Address - Phone:815-459-5600
Practice Address - Fax:815-459-5601
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0190181371223S0112X
WI37211223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIT38692Medicare UPIN
IL761910Medicare ID - Type Unspecified
WI76484Medicare ID - Type Unspecified