Provider Demographics
NPI:1437138047
Name:WARDELL, BRUCE SONNENBERG (DMD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:SONNENBERG
Last Name:WARDELL
Suffix:
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 1:1622 JEANEL LN
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60502-9635
Mailing Address - Country:US
Mailing Address - Phone:630-697-0334
Mailing Address - Fax:
Practice Address - Street 1:45 S PARK BLVD
Practice Address - Street 2:SUITE 220
Practice Address - City:GLEN ELLYN
Practice Address - State:IL
Practice Address - Zip Code:60137-6280
Practice Address - Country:US
Practice Address - Phone:630-469-6200
Practice Address - Fax:630-469-6203
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-12
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL021.0023251223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty