Provider Demographics
NPI:1417977893
Name:BRUECHERT, ROBERT WAYNE II (DMD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:WAYNE
Last Name:BRUECHERT
Suffix:II
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 SW MOODY AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97201-5042
Mailing Address - Country:US
Mailing Address - Phone:360-694-0355
Mailing Address - Fax:360-735-7607
Practice Address - Street 1:2730 SW MOODY AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97201-5042
Practice Address - Country:US
Practice Address - Phone:360-694-0355
Practice Address - Fax:360-735-7607
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA59901223G0001X
ORD6061122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA502-3429Medicaid
WA91-1725083OtherTAX ID NUMBER