Provider Demographics
NPI:1235358508
Name:TEIPEL, BRUCE CARL (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:CARL
Last Name:TEIPEL
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 1:95 W GRAND AVE
Mailing Address - Street 2:SUITE 212
Mailing Address - City:LAKE VILLA
Mailing Address - State:IL
Mailing Address - Zip Code:60046
Mailing Address - Country:US
Mailing Address - Phone:847-356-2336
Mailing Address - Fax:847-356-3295
Practice Address - Street 1:95 W GRAND AVE
Practice Address - Street 2:SUITE 212
Practice Address - City:LAKE VILLA
Practice Address - State:IL
Practice Address - Zip Code:60046
Practice Address - Country:US
Practice Address - Phone:847-356-2336
Practice Address - Fax:847-356-3295
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1915756122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist