Provider Demographics
NPI:1659876852
Name:BRUCHU, CHARLES WILLIAM (DDS)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILLIAM
Last Name:BRUCHU
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 HELMO AVE N STE 130
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-5710
Mailing Address - Country:US
Mailing Address - Phone:651-238-6795
Mailing Address - Fax:
Practice Address - Street 1:1077 HELMO AVE N STE 130
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-5710
Practice Address - Country:US
Practice Address - Phone:651-238-6795
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO00203475122300000X, 1223G0001X
MND146921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist