Provider Demographics
NPI:1114029048
Name:BRUCE HOLMSTROM D.D.S.,SC
Entity Type:Organization
Organization Name:BRUCE HOLMSTROM D.D.S.,SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOLMSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:414-964-8850
Mailing Address - Street 1:5150 N PORT WASHINGTON RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-5474
Mailing Address - Country:US
Mailing Address - Phone:414-964-8850
Mailing Address - Fax:414-964-8918
Practice Address - Street 1:5150 N PORT WASHINGTON RD
Practice Address - Street 2:SUITE 201
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-5474
Practice Address - Country:US
Practice Address - Phone:414-964-8850
Practice Address - Fax:414-964-8918
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5002167-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty