Provider Demographics
NPI:1275712937
Name:HARTWELL, BRUCE G (DD,S)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:G
Last Name:HARTWELL
Suffix:
Gender:M
Credentials:DD,S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 W WINNEBAGO ST
Mailing Address - Street 2:SUITE LL-01
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205
Mailing Address - Country:US
Mailing Address - Phone:414-477-0752
Mailing Address - Fax:
Practice Address - Street 1:901 W WINNEBAGO ST
Practice Address - Street 2:SUITE LL-01
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205
Practice Address - Country:US
Practice Address - Phone:414-477-0752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2009-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5001610-0151223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice