Provider Demographics
NPI:1407967698
Name:BRUCKNER, ROBERT C (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:C
Last Name:BRUCKNER
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:DR
Other - First Name:ROBERT
Other - Middle Name:C
Other - Last Name:BRUCKNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:5402 MINERAL POINT ROAD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-4659
Mailing Address - Country:US
Mailing Address - Phone:608-231-2863
Mailing Address - Fax:608-231-2974
Practice Address - Street 1:5402 MINERAL POINT ROAD
Practice Address - Street 2:SUITE 1
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-4659
Practice Address - Country:US
Practice Address - Phone:608-231-2863
Practice Address - Fax:608-231-2974
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI5001006015OtherLICENSE TO PRACTICE