Provider Demographics
NPI:1932215068
Name:FEHLMAN, BRUCE RICHARD (DDS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:RICHARD
Last Name:FEHLMAN
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:PO BOX 109
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-0109
Mailing Address - Country:US
Mailing Address - Phone:309-944-6401
Mailing Address - Fax:309-945-4311
Practice Address - Street 1:116 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1320
Practice Address - Country:US
Practice Address - Phone:309-944-6401
Practice Address - Fax:309-945-4311
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice