Provider Demographics
NPI:1508864158
Name:REUBEN, BRUCE MICHAEL (DDS, MS)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MICHAEL
Last Name:REUBEN
Suffix:
Gender:M
Credentials:DDS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4200 W PETERSON AVE
Mailing Address - Street 2:SUITE 128
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-6074
Mailing Address - Country:US
Mailing Address - Phone:773-777-6332
Mailing Address - Fax:773-777-6318
Practice Address - Street 1:4200 W PETERSON AVE
Practice Address - Street 2:SUITE 128
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60646-6074
Practice Address - Country:US
Practice Address - Phone:773-777-6332
Practice Address - Fax:773-777-6318
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILT38317Medicare UPIN
IL733070Medicare ID - Type Unspecified